§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
|
Observations:
Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8).
Findings included:
Review of the facility policy "Skilled Nursing-Comprehensive Care Plans" dated August 2024, indicated a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change.
Review of the facility "Elopement Process" dated August 2024, indicated an elopement device should be placed if the resident scores a one or above on the elopement evaluation and are an elopement risk.
Review of the Admission Record indicated Resident R1 was admitted to the facility on 5/10/25, with the diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and history of falling.
Review of Resident R1's Elopement Evaluation Form dated 5/13/25, at 11:08 a.m. indicated resident wanders aimlessly or non-goal directed: Yes. Is the Resident's wandering behavior likely to affect the safety or well-being of self/others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of five.
Review of the Admission Record indicated Resident R2 was admitted to the facility on 5/20/25, with the diagnoses of dementia, repeated falls, and depression.
Review of Resident R2's Elopement Evaluation Form dated 5/20/25, indicated resident wanders aimlessly or non-goal directed: Yes. Wandering behavior likely to affect the privacy of others: Yes. Elopement score of two.
Review of the Admission Record indicated Resident R3 was admitted to the facility on 5/17/23, with diagnoses of dementia, high blood pressure, and insomnia (a sleep disorder where individuals experience difficulty falling asleep, staying asleep or both, leading to daytime impairment).
Review of Resident R3's Minimum Data Set (MDS- a periodic assessment of care needs) dated 5/10/25, indicated the diagnoses remain current.
Review of Resident R3's Elopement Evaluation Form dated 4/22/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Elopement score of three.
Review of the Admission Record indicated Resident R4 was admitted to the facility on 4/1/25, with diagnoses of high blood pressure, renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
Review of Resident R4's MDS dated 4/7/25, indicated the diagnoses remain current.
Review of Resident R4's Elopement Evaluation Form dated 4/1/25, indicated Does the resident have a history of elopement or an attempted elopement while at home: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Elopement score of two.
Review of the Admission Record indicated Resident R5 was admitted to the facility on 3/10/25, with diagnoses of anemia (the blood doesn't have enough healthy red blood cells), hyperlipidemia (high levels of fat in the blood), and depression.
Review of Resident R5's MDS dated 3/16/25, indicated the diagnoses remain current.
Review of Resident R5's Elopement Evaluation Form dated 4/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of four.
Review of the Admission Record indicated Resident R6 was admitted to the facility on 5/12/25, with diagnoses of heart failure (heart doesn't pump blood as well as it should), insomnia, and hyperlipidemia.
Review of Resident R6's Elopement Evaluation Form dated 5/12/25, indicated Does the resident wander: Yes. Elopement score of one.
Review of the Admission Record indicated Resident R7 was admitted to the facility on 12/10/24, with diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), high blood pressure, and heart failure.
Review of Resident R7's MDS dated 4/30/25, indicated the diagnoses remain current.
Review of Resident R7's Elopement Evaluation Form dated 4/26/25, indicated Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Does the resident wander: Yes. Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.): Yes. Elopement score of three.
Review of the Admission Record indicated Resident R8 was admitted to the facility on 8/2/24, with diagnoses of anemia, high blood pressure, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).
Review of Resident R8's MDS dated 4/23/25, indicated the diagnoses remain current.
Review of Resident R8's Elopement Evaluation Form dated 3/3/25, indicated Does the resident have a history of elopement or attempted leaving the facility without informing staff: Yes. Does the resident wander: Yes. Does the resident wander aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings): Yes. Elopement score of three.
Review of eight of eight exit seeking/wandering resident care plans mimicked each other and did not identify any resident person-centered interventions and/or goals specific to each resident.
-Resident R1's care plan dated 5/13/25.
-Resident R2's care plan dated 5/20/25.
-Resident R3's care plan dated 5/21/25.
-Resident R4's care plan dated 4/2/25.
-Resident R5's care plan dated 4/3/25.
-Resident R6's care plan dated 5/15/25.
-Resident R7's care plan dated 5/21/25.
-Resident R8's care plan dated 5/14/25.
Eight of eight resident care plans had almost identical goals of the following:
-The resident's safety will be maintained through the review date.
-The resident will demonstrate happiness with daily routine through the review date.
-The resident will not leave facility unattended through the review date.
Eight of eight resident care plan interventions had almost identical interventions of the following:
-Assess for fall risk
-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book resident prefers:
-Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.
-Monitor for fatigue and weight loss.
-Provide structured activities; toileting walking inside and outside, reorientation strategies including signs, pictures and memory boxes.
Interview on 5/23/25, at 11:30 a.m. the Director of Nursing confirmed the facility failed to make certain exit seeking/wandering residents had a person-centered care plan individualized to each specific resident's needs for eight of 35 residents identified as high risk for wandering/elopement (Residents R1, R2, R3, R4, R5, R6, R7, and R8).
28 Pa. Code 201.24(e)(1)-(5) Admissions Policy
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 06/20/2025
R1, R2, R3, R4, R5, R6, R7, and R8 were not affected by the deficient practice of not identifying person centered interventions for exit seeking/wandering care plans. All exit seeking/wandering care plans for the affected residents were updated with person centered interventions. All residents have the potential to be affected by the deficient practice. A whole house audit was completed to ensure any residents with an exit seeking/wandering care plan has person-centered interventions in place. The nursing team was educated on the importance of developing and implementing these person-centered care plans by DON or designee. The DON or designee will conduct an ongoing audit of any new residents coming to the community to ensure if they are appropriate to receive an exit seeking/wandering care plan that person-centered interventions are present within it. These audits will occur 7 days a week for two weeks, 5 days a week for two weeks, and then 3 days a week for two weeks (total 6 weeks). The results of these audits will be shared with the Administrator and reviewed with our QAPI team.
|
|
