|§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.
Based on clinical record review, and observation, it was determined that the facility failed to implement care planned interventions for one of five sampled residents. (Resident R1)
Clinical record review revealed that Resident R1 had diagnoses that included dementia, pulmonary embolism (obstruction of blood clot) and repeated falls. The Minimum Data Set assessment dated April 3, 2019, indicated that the resident had memory impairment and required extensive assistance from staff for most activities of daily living including dressing, transfers and bed mobility. Review of a physician's order since December 9, 2016, revealed that the staff were to apply compression stockings (TEDS) in the morning and remove at night. Review of the current care plan revealed that the resident was at risk for complications related to a diagnosis of bilateral pulmonary embolism and an intervention was for staff to apply the TEDS in the morning and remove at night. Observation on April 25, 2019, at 11:30 a.m., and 12:30 p.m., revealed that the resident was dressed but did not have the TEDS stockings in place. In addition, the resident had a physician's order since December 2016 to have a high/low bed with bilateral fall mats. Review of the current care plan revealed that the resident was at risk for falls due to a history of falls and an intervention was for staff to place bilateral floor mats on the floor when the resident was in bed. Observation on April 25, 2019, at 11:30 a.m., revealed that the resident was in bed without the bilateral floor mats in place.
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(5) Nursing services.
| ||Plan of Correction - To be completed: 06/23/2019|
Regarding Resident R1, TED hose were immediately applied and floor mats put in place.
Unit Staff for Resident R1 was immediately re-educated by nursing supervisor and ADON regarding following care cards.
Re-training will be provided as stated below.
Results will be discussed at the QAPI meeting to ensure compliance and further audits will be added if necessary.