§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 review of clinical records and grievances lodged with the facility and staff interview, it was determined that the facility failed to notify a resident's representative of an unwitnessed fall incurred by one resident out of five sampled (Resident 4).
Findings include:
A review of the clinical record revealed that Resident 4 was admitted into the facility on October 18, 2023, with diagnoses including chronic kidney disease and dementia.
A nurse's note dated December 23, 2023, at 4:30 PM, but entered into the record on December 24, 2023, at 7:33 PM revealed that the resident had an unwitnessed fall and staff found the resident on the floor. The entry noted that the resident's physician and responsible party were notified of the fall.
A review of a facility concern/grievance form dated January 15, 2024, revealed that Resident 4's responsible part stated that she was not notified of Resident 4's fall on December 23, 2023.
An interview with the Director of Nursing on January 31, 2024, at approximately 2 PM confirmed the facility failed to timely notify the resident's responsibility party of the resident's fall at the time of occurrence as noted in the resident's clinical record. She further confirmed that Employee 5 (LPN) wrote the nurses note indicating that she had contacted the resident's responsible party, but she had not contacted the responsible party at that time.
28 Pa. Code 211.12 (d)(5)Nursing services
28 Pa. Code 201.29 (a) Resident rights
| | Plan of Correction - To be completed: 03/12/2024
1. Resident #4 resides in the facility. Her most recent fall was January 15, 2024. Resident representative was notified of fall at time of occurrence and documented appropriately. 2. The twenty-four-hour report will be reviewed during morning clinical meeting to ensure resident representatives have been notified of falls timely. 3. "Resident Change in Condition Notification" policy will be reviewed. Licensed nurses will be in serviced on this policy. 4. DON/Designee will randomly audit nursing documentation to ensure resident representative have been notified when a fall occurs. Random audits will be conducted weekly x 4 weeks, then monthly x 3 months. Findings of audits will be reported to the Quality Assurance/Performance Improvement Committee monthly.
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