|§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, observations and interviews with staff and residents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet each residents' needs for three of twenty-eight residents reviewed (Residents R31, R53, R62).
Review of the comprehensive Minimum Data Set (MDS-assessment of resident care needs) dated 12/18/2018 indicated that Resident R53 weighed 154 pounds. The comprehensive assessment dated March 29, 2019 indicated that the resident weighed 138 pounds. A weight decrease of 16 pounds over a three month period of time was recorded which represented a significant weight loss. The comprehensive assessment MDS dated April 26, 2019 for Resident R53 indicated that this resident's cognition was moderately impaired.
Interview with Resident R53 on May 22, 2019 at 11:10 a.m., revealed that the resident was trying to eat as much as possible and that this resident was interested in between meal supplemental foods to meet nutritional needs for weight gain.
A review of the resident's food consumption documented in the clinical record for breakfast, lunch and dinner during April 25, 2019 through May 21, 2019, revealed that this resident had poor food intake for the breakfast meal. Continued review of Resident R53's clinical record revealed no documentation to indicate that a care plan had been developed and implemented to address the resident's poor food consumption.
Review of the dietitian's progress note dated April 24, 2019 revealed that Resident R53 had poor intake and the resident was scheduled for an abdominal PEG (tube placed surgically through the abdomen into the stomach used for feeding) tube placement on May 13, 2019. Interview with Employee E2 director of nursing, on May 21, 2019 at 1:00 p.m., revealed that the resident did not have the tube surgically placed..
Interview with Employee E4, dietitian, on May 22, 2019 at 9:00 a.m., confirmed that there was no nutritional care plan developed and implemented for Resident R53's poor food consumption as documented by the nursing staff for April 25, 2019 through May 21, 2019.
Review of the clinical record for Resident R31 revealed a comprehensive Minimum Data Set (MDS-an assessment of resident care needs) dated January 2, 2019, which indicated that the resident required extensive assistance of two staff persons for bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed). The MDS also indicated that this resident was exhibiting physical behavioral symptoms directed toward others (hitting, kicking, pushing scratching, grabbing) and that this resident was incontinent of bowel and bladder).
Continued review of the clinical record revealed a comprehensive MDS assessment dated March 25, 2019 which indicated that the resident had a history of a fall with injury (skin tear, abrasion, laceration). The resident was severely cognitively impaired, non-ambulatory (unable to walk) and totally dependent on the assistance of one staff for locomotion (how the resident moves between locations in his/her room or corridor). The assessment also indicated that the resident had no functional limitations of the upper and lower extremities and that Resident R31 was incontinent of bowel and bladder.
Clinical record review further indicated that Resident R31 had two falls (March 13, 2019 and October 14, 2018), that required a hospital evaluation. On March 13, 2019 Resident R31 fell from bed while one staff member was providing incontinence care. Clinical record documentation indicated that the resident was resistive with care at that time. Further review of Resident R31's clinical record revealed there was no care plan developed and implemented for Resident R31 related to bed mobility and behavioral symptoms.
Clinical record documentation for October 14, 2018 indicated that a staff member was transporting Resident R31 in a high-back wheelchair, when the resident impulsively fell forward out of the chair resulting in a laceration to the forehead. The clinical record indicated that after this fall, the resident was to use a wheelchair (Broda), that was to be reclined during transporting the resident to prevent further falls. Observation of Resident R 31 being transported by staff in the hallway at 1:30 p.m., on May 23, 2019, revealed that the resident was not reclined as care planned to prevent accidents and injury.
Interview with Employee E5, occupational therapist, on May 24, 2019 at 9:30 a.m., revealed that the reclining ability of the chair was not functioning properly on May 23, 2019. The interview further revealed that the therapist had adjusted/tightened the resident's wheelchair (Broda) on May 23, 2019. The occupational therapist confirmed during the interview that the care plan had not been implemented as planned for Resident R31.
Review of the clinical record and the hospital record for Resident R62 revealed that the resident admitted to the facility on April 22, 2019, with a diagnosis of complete traumatic amputation (loss of limb) of the right great toe complicated by osteomyelitis (infection of the bone). Observations of Resident R62 on May 21, 2019 at 11:30 a.m., revealed that the resident had a left upper extremity PICC (peripherally inserted central catheter) line. Further review of clinical record indicated a physician order dated April 22, 2019, which directed staff to change the double lumen PICC line every seven days.
Review of the facility policy for the care of a peripherally inserted central catheter (PICC) line dated March 2019 was to have the PICC dressing changed twenty-four hours after insertion, then have the PICC dressing changed every five to seven days, or sooner, if the dressing becomes soiled, wet or not intact. The policy further indicated that the PICC site was to be assessed for complications and possible migration or malfunction.
A review of Resident R62's clinical record revealed no documentation that the facility had developed a comprehensive care plan for the assessment and monitoring for the care and maintenance of PICC line. Interview
with Employee E2, Director of Nursing, at 2:45 p.m. on May 24, 2019, confirmed the finding.
28 Pa. Code: 211.11(a)(b)(c) Resident care plan.
28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.
Previously cited 6/29/18.
| ||Plan of Correction - To be completed: 07/05/2019|
Resident R53 has been seen by the facility's registered dietitian, interventions have been discussed with the resident, and a care plan is in place.
Resident 31 has been reviewed by the therapy department, the care plan has been reviewed, and staff will be educated on the resident's care plan interventions.
Resident R62 has been successfully discharged from the facility.
An audit will be conducted for all residents that have had a significant weight loss as defined by the MDS, to ensure appropriate interventions are in place. An audit will be conducted for all residents that have a PICC line, to ensure a care plan is in place for the care of the PICC line. An audit will be conducted for all residents that have had a fall in the last 60 days, to ensure an appropriate care plan is in place.
Audits will continue for interventions for residents that have had a significant weight loss as defined by the MDS, have a PICC line, or have had a fall, for the next 12 weeks, to ensure the intervention(s) is appropriate and being followed as care planned.
Results of the audits will be taking to the quality assurance performance improvement committee for discussion and recommendations. The director of nursing or designee will be responsible for these audits.