|§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 review of facility policies and clinical records and staff interviews, it was determined that the facility failed to develop comprehensive plans of care for three of 24 residents (Residents R13, R69 and R87).
A review of the facility policy "Comprehensive Care Plans" dated 11/28/19, indicated that a comprehensive plan of care will be developed for each resident and will describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.
A review of the facility policy "Smoking Policy" dated 11/28/19, indicated that the Interdisciplinary Team will develop an individualized plan of care for each resident who smokes. It will include interventions specific to the needs of the resident based upon the assessment to include the level of supervision needed.
A review of the Admission Record indicated Resident R13 was admitted to the facility on 1/30/19, and the Minimum Data Set (MDS-periodic assessment of care needs) dated 3/7/19, revealed diagnoses that included high blood pressure, irregular heart rhythm, and a history of falls. An order dated 2/23/19, indicated hospice services for end of life care.
A review of Resident R13's plan of care revealed there was no care plan to address end of life care.
A review of the Admission Record indicated Resident R69 was admitted to the facility on 4/26/19, with diagnoses that included pneumonia, an irregular heart rhythm and anxiety disorder.
During an interview on 5/28/19, at 10:15 a.m. Resident R69 became tearful regarding her current health condition that has included "several set-backs."
A review of the progress notes from 4/26/19 through 5/29/19, revealed several entries referencing Resident R69's emotional state exhibited by tearfulness. Social Service note dated 5/2/19, indicated that Resident R69 was recommended to be seen by Med Options for psychiatric services and she declined.
A review of the plan of care revealed that there was no care plan to address Resident R69's emotional state exhibited by tearfulness and unwillingness to be seen by the psychiatrist.
A review of the Admission Record indicated Resident R87 was admitted to the facility on 1/25/19, and MDS dated 5/7/19, indicated diagnoses that included chronic breathing/lung problems with oxygen dependence, an infection in her urine, depression and insomnia.
A review of the smoking assessment dated 5/28/19, indicated that she smokes 5-10 cigarettes a day, that she can light her own cigarette and that she is safe while smoking.
A review of the plan of care revealed that there was no care plan to address Resident R87's smoking needs.
During an interview on 5/31/19, at 12:45 p. m. Assistant Director of Nursing Employee E10 confirmed that the facility failed to develop comprehensive plans of care for Resident R13, R69 and R87.
28 Pa. Code: 211.11 (a) (b) (c) (d) (e) Resident care plan.
| ||Plan of Correction - To be completed: 07/09/2019|
Residents R13, R69, R87 care plans were updated on 5-31-19 to reflect smoking, tearfulness with unwillingness to be seen by a Therapist, and election of Hospice services.
For residents with like situations, conditions, or election of adjunct services, social services or designee will be notified by hospice providers when a resident elects hospice. Upon notification from hospice provider of resident officially on hospice, social services or designee will notify nursing to initiate a hospice care plan.
For residents in similar emotional situations, residents will be evaluated initially by social service assessment and throughout stay through clinical orders review and behavior meetings. Social services will initiate a care plan once identified.
For like residents who smoke, upon admission, the admitting nurse will ask resident if the resident smokes. A smoking evaluation will be completed by admitting nurse upon admission if the resident smokes. A smoking care plan will be implemented by the admitting nurse.
Compliance for hospice care plan and emotion care plan will be monitored by social services daily for 5 days, weekly for 3 weeks, monthly for 2 months and quarterly for two quarters.
Compliance for the smoking care plan will be monitored Nursing supervisor or designee to monitor each shift daily for 5 days, three times a week for three weeks, weekly for 4 weeks, monthly for 2 months, quarterly for 2 quarters.
Audit results will be presented by Director of Nursing and Social Service Director to Quality Assurance Performance Improvement Committee to determine resolution or need for continued monitoring.