§483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed.
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Observations:
Based on a review of clinical records and select facility reports and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that fully addressed a resident's behavior management, included repeated non-compliance with the facility's leave of absence policy, to consistently meet the resident's safety needs for one resident out of 10 sampled (Resident A1).
Findings included:
A review of Resident A1's clinical record revealed admission to the facility on April 14, 2023, with diagnoses including diabetes, depression and a history of falling.
Resident A1's quarterly Minimum Data Set (MDS - a federally mandated assessment of a resident's abilities and care needs) dated December 13, 2023, revealed that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status Score - a tool to assess cognitive function).
A review of Resident A1's care plan, initially dated April 21, 2023, indicated that Resident A1 has potential to exhibit increased behaviors as evidenced by ineffective coping and increased anxiety. Interventions planned were to document on Behavior Monitoring form each episode, Elicit family input for best approaches for resident, Keep schedules routine & predictable, remove resident from public area when behavior is disruptive/ unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and Praise/ reward resident for demonstrating consistent desired/ acceptable behavior. The care plan also noted that the resident exhibits increased behaviors as evidenced by inappropriate behavior; resistive to treatment/care (Refuses: medications/treatments, insulin, wound treatment changes, labs, wound vac (removes wound vac himself), non-compliant with therapy transfer recommendation; non-compliant with leave of absence facility policy, related to Anxiety diagnosis, initiated May 1, 2023. A review of a nurses note dated June 5, 2023, at 2:25 P.M revealed that the resident was out of the facility in wheelchair, with family to celebrate his birthday.
A review of a nurses note dated June 6, 2023, at 12:27 AM revealed "called \ several times, about 4 or 5 times, he finally picks up and said he is with his friend and that his friend threw him a party. He also stated that he called the facility around 8:30 PM and left a voice mail. I advised he cannot be out passed midnight if he did not already state that he would be out that long. He understood and said he is coming back."
A review of a nurse's note dated June 6, 2023, at 12:51 AM revealed "called A1) again at 12:51 AM resident stated he is on his way, the person driving him had to stop for gas."
A review of a nurses note dated June 6, 2023, at 01:09 AM "called resident again, resident states he is 15 minutes away. " Nursing noted on June 6, 2023, at 01:37 AM revealed that Resident A1 was now back to facility and in room."
A nurse's note dated August 4, 2023, at 5 PM revealed that Resident A1 was on LOA with family. Nursing noted on August 4, 2023, at 11:03 PM revealed "nurse reported to this RN that resident isn't back to the facility. I advised calling him and when nurse called resident stated he is 15 minutes away."
A nurses note dated August 5, 2023 at 02:00 AM revealed "Nurse reported to this RN that resident isn't back to the facility. I advised calling him and when nurse called resident stated he is 15 min away." A review of a nurses note dated August 5, 2023, at 02:59 A.M. revealed that Resident A1 was back to facility now
A nurses note dated August 19, 2023, at 4 PM revealed, Resident LOA with friends to clean a house. A review of a nurses note dated August 20, 2023 at 12:14 AM revealed "Resident not yet back in the facility, gave him a call and he said he was coming."
A review of a nurse's note dated August 20, 2023, at 04:01 AM revealed "gave Resident a call and he confirmed he would be here shortly."Nursing noted on August 20, 2023 at 06:22 AM revealed that the resident not yet back from his evening out. A review of nursing documentation dated August 20, 2023 at 07:05 AM, revealed "Resident telephone line not recharged, voice mail left on the sister's phone." A nurses note dated August 20, 2023 at 08:28 AM revealed that the resident returned back to the facility.
A review of a nurse's note dated September 20, 2023, at 6:08 P.M. revealed "Resident LOA to a friend's house. Resident stated he'll be back some time tonight."
A review of a nurses note dated September 20, 2023, at 11:39 PM revealed "Resident called the facility to let this Nurse know that he was waiting for his ride and he would be back to the facility in about an hour. The resident was educated about coming back to the faculty on time."
A review of a nurses note dated September 21, 2023 at 1:32 A.M. revealed "Resident called the facility at 1:30 A.M. to let this Nurse know that he was still waiting for his ride. RN Supervisor made aware." A review of a nurses note dated September 21, 2023, at 4:22 AM revealed that the resident had yet to return to the facility. A review of a nurses note dated September 21, 2023, at 07:09 AM revealed "Resident LOA from facility for the tour of the shift. Spoke to resident several times during the night which he stated that he was waiting for a ride home. RN Supervisor made aware of the resident status. Will report to on boarding Nurse." A review of a nurses note dated September 21, 2023 at 08:42 A.M. revealed that the resident had returned to facility from LOA. The resident had been out of the facility from September 20, 2023, until September 21, 2023, at 8:42 AM.
A review of a facility investigation dated February 2, 2024, at 6:41 PM revealed that on February 1, 2024, at 2:05 PM Resident A1 left the facility with a friend. He had verbalized to nursing staff at approximately 12:45 PM that he "would not be needing lunch as he would be going out." The report noted that the resident did have an LOA (leave of absence) physician order and was aware of the facility policy to sign out with nursing prior to leaving the facility. However, the resident left the facility without signing out according to the facility LOA policy.
The report further indicated that nursing staff attempted to contact the resident via his personal cell phone at approximately 4:38 AM on February 2, 2024, as the resident had yet to return to the facility. The resident did not answer his cell phone. Staff contacted the resident's emergency contact #2 and she did not know where the resident was at that time. The RN charge nurse was made aware per a nurses note in the clinical record. The Nursing Home Administrator (NHA) arrived at the facility at 7 AM on February 2, 2024. After reading the clinical nursing shift report, the NHA asked nursing staff if Resident A1 had returned to the facility as there was no documentation of the same in the resident's clinical record. Nursing staff, at that time had reported to the NHA that Resident A1 was still on leave of absence since 2:05 PM on February 1, 2024.
The immediate action noted was the NHA attempted to contact the resident via his personal cell phone three times, but the resident did not answer. A facility and ground search was conducted. All hospitals in the county were contacted for possible hospital admission. The local police department was contacted and a missing person report was filed.
On the facility security camera system, the NHA was able to identify the license plate number of the resident's friend who had left the facility with the resident. The resident was located at a local hotel with a friend by the local police department. The resident was deemed safe by the police and offered him a ride back to the facility by the facility van. Resident A1 refused, he reported to the NHA that he would be returning to the facility via his friend's car as soon as possible. Resident A1 returned to the facility February 2, 2024 at 12:48 PM.
The care plan was not updated until February 2, 2024, to include the following "\ was made aware by the nursing home administrator and social services director, regarding facility policy of leave of absence and expresses understanding of same."
During an interview on February 14, 2024, at approximately 2:00 p.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to timely address the resident's repeated behavior of leaving the facility for extended periods of time without the facility's knowledge of his whereabouts and continued non-compliance with the facility's leave of absence policy to ensure resident safety.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 04/08/2024
Plan of Correction: 1. The facility cannot retroactively correct the failure to develop a person-centered care plan that timely addressed behavior management in resident A1's care plan. 2. Resident A1's care plan updated to reflect behaviors. 3. Behaviors will be reviewed in morning clinical start up with review of resident care plans to ensure revisions were completed as necessary. 4. DON or designee to complete random audits of resident care plans to ensure all behaviors are incorporated into each resident care plan as necessary weekly for four weeks and monthly for two months. 5. Audits will be submitted to QAPI for review and recommendations.
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