§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).
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Observations:
Based on a review of clinical records and medication error reports and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a fall for one out of 22 residents sampled (Resident B1).
Findings include:
A review of Resident B1's clinical record revealed that the resident was admitted to the facility on September 18, 2023, with diagnoses to include, osteoarthritis, spinal chronic kidney disease, dementia and a history of falling.
A facility investigation report and nursing documentation dated January 1, 2024, at 1:41 PM revealed that staff found Resident B1 on the floor in her room, between her bed and the wheelchair, after the resident attempted to self transfer. Nursing noted that the resident sustained no apparent injury, denied discomfort and was able to move all extremities without discomfort. It was noted that the resident's non-skid socks had been applied incorrectly. Staff reapplied the socks. The resident was referred to therapy for evaluation and treatment.
There was no documented evidence a the time of the survey ending March 12, 2024, that the designated representative was timely notified of this fall.
Refer F726
28 Pa. Code 211.12 (d)(3)(5) Nursing services
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 04/04/2024
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Grandview Nursing & Rehabilitation agrees with the allegations and citations listed on the statement of deficiencies.
Grandview Nursing & Rehabilitation maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Grandview Nursing & Rehabilitation's written credible allegation of compliance.
By submitting this plan of correction, Grandview Nursing & Rehabilitation does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Grandview Nursing & Rehabilitation reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
1. Resident B1's POA/RP was notified of the fall which occurred by LPN on 1/1/24 at 1456 as documented in the incident record. 2. Facility wide audit of incidents from 3/17/24 completed to ensure resident representatives were notified consistent with his or her authority as indicated by 483.10(g)(14)(i)-(iv)(15). 3. Licensed nursing staff were educated on §483.10(g)(14) Notification of Changes. Clinical follow up tracking developed to facilitate increased communication of resident incidents. 4. The DON or designee will review previous days incidents during AM clinical meeting to ensure resident representatives were notified five times per week x 3 weeks, weekly x 3 weeks, monthly x 3 months. 5. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met
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