§483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
§483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
|
Observations:
Based on review of clinical records, resident and staff interview, it was determined that the facility failed to timely notify a resident's representative of significant decline in the condition of a wound for one resident out of four sampled (Resident 104).
Findings include:
A review of the clinical record revealed Resident 104 revealed that the resident had diagnoses of quadriplegia (paralysis of all four limbs), pressure ulcer, anxiety, protein-calorie malnutrition, neuromuscular dysfunction of the bladder, and osteomyelitis (infection in the bone).
A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated January 2, 2024, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 14 (13 - 15 represents cognitively intact).
The resident's clinical record identified that the resident had interested representatives noting primary and secondary contacts.
A wound note dated December 10, 2023, at 2:52 PM, indicated that during a shower a new pressure sore was identified on the resident's coccyx, which measured 3 centimeter (cm) x 1.5 cm x 0.2 cm with a grey slough center. The note indicated that the resident's responsible party was aware and a wound note dated December 10, 2023, at 10:49 PM, clarified that the resident's father/RP was notified.
A review of a health status update dated December 17, 2023, at 10:38 PM indicated that the resident presented an acute onset of altered mental status. LPN notified the resident's mother and the resident was transported to the hospital. A review of a health status update dated December 18, 2023, at 5:22 AM indicated that the resident was admitted with diagnosis sepsis.
A review of a nursing note dated December 21, 2023, at 10:28 AM indicated Resident 104 returned from hospital approximately 9:30 AM in stable condition.
A clinical admission note dated December 21, 2023, at 10:38 AM indicated that the resident had an left buttock unstageable pressure ulcer, obscured full thickness skin and tissue loss.
A nursing note dated December 25, 2023, at 11:20 AM indicated Resident 104 went on leave with his father and family until approximately 5:30 PM. The family provided transport via private vehicle.
A late entry CRNP (certified registered nurse practitioner) note, dated January 15, 2024, at 4 PM indicated that the resident's left gluteal area is worsening, "wound has declined." The entry noted that the "Resident is a quadriplegic and does not get out of bed much. Awake, alert, capable, oriented x 3 makes needs known. Makes own medical decisions, however, seems lax about wound situation which is likely because he cannot see or feel wound or pain after wound assessment. Made resident aware wound is much worse and bone palpable. Getting Xray rule out osteomyelitis. He is at high risk for infection, sepsis, and even death if that happens and we need to keep wound clean and treatment done as ordered. Certified Nursing Assistant (CNA) and LPN present for education and conversation with patient regarding telling him worsening status of wound and risk for sepsis/death."
There was no documented evidence that the resident's representative was notified of the resident's worsening wound and risk for infection, sepsis and even death as noted by the CRNP in the late entry note on January 15, 2024.
A radiology note dated January 16, 2024, at 6:34 PM, indicated that the results were reviewed with the provider and the facility was awaiting new orders. Nursing noted on January 16, 2024, at 7:06 PM that the resident has a new diagnosis of Osteomyelitis, will need to consult infectious disease (ID), PICC line placement and IV antibiotic administration. Request sent for need ID consultation. All other orders placed as appropriate. Nursing noted "Resident is own RP and notified of same."
A review of a nursing note dated January 17, 2024, at 8:12 AM indicated contact made with CRNP, resident will have to go to the hospital emergency department (ED), they might admit him to have him seen by ID and for a PICC for diagnosis of osteomyelitis. Resident informed he needs to be evaluated at the ED.
A review of a communication with family/representative note dated January 17, 2024, at 8:33 AM indicated that the facility called the resident's responsible party, his father, and his emergency contact, his stepmother, to update them on the resident's resident current status.
Interview with Resident 104 on February 7, 2024, at approximately 12:05 PM, the resident stated that he would prefer his family be made aware, along with himself of his health conditions, changes.
There was no indication that the resident's responsible party was timely notified, nor that the resident had refused family notification, of his significant change in the status of his wound, its deterioration, which was potentially life threatening, requiring a change in treatment and emergency services.
An interview with the Director of Nursing (DON) on February 7, 2024, at approximately 2:20 PM confirmed that the clinical record failed to identify that the resident's responsible party was timely notified of the significant decline noted on January 15, 2024, until January 17, 2024, nor evidence that the resident had refused notification of his family.
An interview with the Nursing Home Administrator (NHA) on February 7, 2024, at approximately 2:40 PM confirmed that her expectation would be that the facility timely notify the responsible party of changes in resident's condition.
28 Pa. Code 201.29 (a) Resident rights
28 Pa Code 211.12 (d)(3) Nursing services
| | Plan of Correction - To be completed: 03/13/2024
1. Resident 104 responsible party has been notified of change in condition. 2. Current resident progress notes for February 20, 2024, to Feb 27, 2024, will be reviewed by the DON/designee to validate that the responsible parties have been made aware of changes in condition. 3. Education will be provided to the licensed nurses by the DON or designee on notification to RP of changes in resident's condition. 4. A notification audit will be completed by the DON or designee to validate that RP/residents were made aware of changes in condition weekly x 4 weeks. Results of the audits will be reviewed with the Quality Assurance Performance Committee.
|
|