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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: March 21, 2025
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #NY 390) completed on 10/11/2022, the facility did not ensure that the resident representative was notified of a change in condition for one (1) (Resident #3) of eight (8) residents reviewed. Specifically, the facility did not ensure Resident #3's Health Care Proxy (HCP) was notified when the resident received a [DIAGNOSES REDACTED].#3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 1/7/2021, documented the resident could sometimes be understood and could sometimes understand others. A Brief Interview of Mental Status (BIMS) score was not assessed as the resident rarely/never understood. The resident's medical record did not document the resident's Health Care Proxy was notified after the resident tested positive for Covid-19 on 1/2/ 2021. According to the facility record, there was no communication with the resident's HCP following the change in condition until 1/11/ 2021. A progress note dated 1/2/2021 at 4:26 PM, documented the resident tested positive for COVID- 19, but was not showing any signs or symptoms at the time. There was no documented communication with the resident's HCP. A progress note dated 1/2/2021 at 1:34 AM, documented the resident had developed a temperature of 101. 7 and was provided Tylenol 650 MG. The supervisor was made aware, will monitor temperature and effect of Tylenol, cool compresses applied to forehead, neck, underarms, given fluids. There was no documentation that the resident's HCP was contacted. A progress note dated 1/5/2021 at 2:23 AM, documented the resident had a temperature of 100. 9 and was given Tylenol 650 MG for the elevated temperature. There was no documentation that the resident's HCP was contacted. A nursing progress note dated 1/11/2021 at 3:47 PM, documented the writer contacted the HCP to update them when the resident was found in the room non-verbal and not responding to staff. A nursing progress note, dated 1/12/2021 at 11:42 AM, documented All parties were made aware that Resident #3 was Covid positive on 1/11/ 2021. During an interview on 9/23/22 at 11:25 AM, the Staff Development Coordinator (SDC) who is a Nurse Supervisor at the facility stated that whenever a change in condition the physician and family should be notified immediately. There is an in-service that is provided to staff which trains them on the procedure to follow and notifications to make when a resident has a change in condition. During an interview on 9/23/22 at 11:30 AM, the Assistant Director of Nursing (ADON) stated that any time there is a change in condition for a resident we call the family and the physician right away. They said If there is decline happening, the facility will frequently provide updates to the resident's family as they are occurring. During an interview on 9/23/2022 at 2:30 PM, the Director of Nursing (DON) stated that the facility was in outbreak in (MONTH) of 2020. Robocalls were sent out to alert the families of COVID-19 outbreak status. The system can alert an individual or groups. During the interview, the DON was asked to confirm communication of the notification of change due to COVID-19 with the HCP for Resident # 3. The DON provided robocall confirmations dated 1/4/2021 and 1/14/ 2021. 10 NYCRR 415. 3(e)(2)(ii) | Plan of Correction: N/A Plan of correction not approved or not required |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: April 2, 2025
Corrected date: March 21, 2025
Citation Details None | Plan of Correction: N/A Plan of correction not approved or not required |