§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 clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to develop a comprehensive person-centered care plan for two of 22 residents reviewed (Residents 1 and 77).
Findings Include:
Review of Resident 1's clinical record documented diagnoses that included anxiety (a feeling of worry, nervousness, or unease), depression (feelings of severe despondency and dejection), dysphagia (difficulty swallowing), and dementia (a condition characterized by progressive loss of intellectual functioning, and impairment of memory and abstract thinking).
During an interview with Resident 1 on January 2, 2024, at 10:01 AM, it was revealed he wears dentures, his gums were sore at that time, and would like to see a dentist for his sore gums. Resident stated that when he bites down, it causes pain in his lower gum. Resident stated he hadn't been seen by a dentist while at the facility.
Observation on January 2, 2024, at 10:01 AM, Resident 1 was wearing full upper dentures, his bottom jaw was edentulous, and his gums were reddened.
Resident 1's December 2023 physician orders included Orajel Mouth/Throat Gel 10 % (Benzocaine (Dental)- topical pain killer) Give one application orally three times a day for Oral ulcers, start date December 1, 2023.
Resident 1's December 2023 Medication Administration Record (MAR - documentation of medication administered) documented Orajel was administered orally three times a day for oral ulcers, started December 1, 2023; and First-mouthwash BLM mouth/throat suspension (magic mouthwash- medication used to treat oral ulcers and mouth pain) was administered one time a day for mouth ulcer December 12, 2023, through December 18, 2023; administered as ordered.
Review of Resident 1's progress notes documented on December 1, 2023, revealed the Resident complained of oral pain/discomfort, nurse noted small red inflamed areas to upper and lower gums under denture lining, and the physician was made aware and ordered Orajel three times a day until healed.
Further review of progress notes documented on December 11, 2023, Certified Registered Nurse Practitioner ordered magic mouthwash for ulcers in Resident 1's mouth for seven days.
Review of nursing note on December 27, 2023 documented the Resident receiving Orajel for recent mouth sores.
Review of Resident 1 care plan on January 2, 2023, failed to include documentation of dentures and mouth pain/ulcers.
During an interview with the Director of Nursing (DON) on January 3, 2024, at 1:10 PM, it was revealed that Resident 1 has upper and lower dentures and is able to care for his dentures himself.
Further review of Resident 1's care plan on January 4, 2024, documented a focus area for dental health problems due to injury related to dentures with complaint of mouth pain, initiated on January 3, 2024; with interventions that included mouth inspections as needed, report changes to nurse, and to observe/document/report to provider signs or symptoms of dental problems.
During an interview with the DON on January 4, 2024, at 10:36 AM, it was revealed a dental care plan should've been initiated prior to January 3, 2024.
Review of Resident 77's clinical record revealed diagnoses that included gastro-esophageal reflux disease (GERD- acid reflux) and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar).
Review of Resident 77's current physician orders, revealed an order dated September 21, 2023, for a hospice consult evaluation and treatment.
Review of Resident 77's progress notes revealed a note dated September 28, 2023, stating that Resident 77 is on hospice services as of September 28, 2023.
Review of Resident 77's significant change MDS (Minimum Data Set- an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs), dated October 11, 2023, revealed that Resident 77 was marked as receiving hospice services.
Review of Resident 77's current care plan failed to reveal a hospice care plan.
On January 3, 2024, at 1:13 PM, the DON provided a hospice care plan for Resident 77 that was initiated on January 3, 2024. At that time, the DON stated that the hospice care plan should have been initiated prior to this date.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 03/01/2024
1. The comprehensive care plan for Residents 1 and 77 were updated on January 3, 2024.
2. Audits will be completed for all residents on hospice and those with documented dental pain for care plan accuracy.
3. NHA/designee will re-educate the IDT team on the comprehensive care plan standard of practice.
4. Weekly audits of care plans for accuracy to occur in accordance with the care plan conference schedule x8 weeks. Audits will be reviewed at the QAPI meeting for follow and additional recommendations.
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