|§483.10(c) Planning and Implementing Care. |
The resident has the right to be informed of, and participate in, his or her treatment, including:
§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.
§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.
§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Based on clinical record review and interviews with staff, it was determined that the facility failed to inform a resident's family member of significant weight loss for one of three residents reviewed (CL1).
Review of CL1's clinical record revealed an admission date of February 6, 2019, with the diagnosis of congestive heart failure, (a chronic condition in which the heart doesn't pump blood as well as it should.), type 2 diabetes, (a chronic condition that affects the way the body processes blood sugar), and chronic kidney disease, (longstanding disease of the kidneys leading to renal failure).
Further review of CL1's clinical record revealed documentation that on January 6, 2020, resident experienced a significant weight loss of 7% (11 lbs) in one month. The clinical record revealed on January 7, 2020, that "the physician made aware of the weight changes and the physician to speak to the Power of Attorney".
An interview conducted with Licensed Physician, Employee E3, on January 23, 2020, at approximately 1:30 p.m. revealed that the facility staff did notify them of the weight change but did not communicate that Employee E3 was supposed to notify the Power of Attorney.
A second interview was conducted with the Nursing Home Administrator on January 23, 2020, at approximately 2:30 p.m., confirmed that the facility failed to notify the family of the significant weight loss.
28 Pa Code 201.29(j) Resident rights
| ||Plan of Correction - To be completed: 02/25/2020|
1. R1's physician and family were made aware of the weight loss.
2. Comprehensive review of the past 14 days for those with significant weight loss to ensure their POAs have been notified.
3. Licensed nurses & nutritional service department has been re-in serviced on notifications for those with significant weight loss.
4. Weekly audit for those residents having experience a significant weight loss to ensure proper notification. The weekly audits will be performed for four weeks and then brought to the facility Quality Assurance/Improvement Committee for the need of further audits.
5. The alleged date of compliance is 2/25/2020.