|§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 resident and staff interview, and clinical record review, it was determined that the facility failed to ensure a comprehensive plan of care was developed and implemented for two of 35 resident records reviewed (Residents 77 and 158).
Review of Resident 77's clinical record on March 18, 2019, at approximately 2:00 PM revealed diagnoses that included end stage renal disease (extremely diminished function of the kidneys which results in the need for life sustaining dialysis - process of using a machine to filter toxins from the blood), and diabetes mellitus type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood to the cells for nourishment).
During a resident interview on March 18, 2019, at approximately 1:30 PM Resident 77 revealed that his discharge planning included transfering to a lesser care facility or transferring to a separately licensed facility.
Review of Resident 77's comprehensive plan of care on March 20, 2019, at approximately 1:20 PM revealed that Resident 77 did not have a care plan to address his discharge. Review of Resident 77's resolved and cancelled care plans revealed "[Resident 77] shows potential for discharge and patient, and [representative party] express wish for discharge," was resolved on February 23, 2019.
Review of Resident 77's progress notes on March 21, 2019, at approximately 10:15 AM revealed that Social Services Personnel 1 (SSP) 1 documented on February 25, 2019 that Resident 77 was planning to return to an assisted living facility or remain at the facility. Review of the progress notes revealed that SSP 1 documented Resident 77's discharge plans, and changes to Resident 77's discharge plan on February 26, 28, 2019 and March 4, 6, 13, and 15, 2019.
Review of Resident 77's clinical record revealed that Resident 77 did not have a discharge plan of care between February 23, 2019, to March 21, 2019.
During an interview on March 21, 2019, at approximately 1:45 PM, Director of Nursing revealed it was the facility's understanding that the care plan for Resident 77's discharge was resolved on February 23, 2019. During the staff interview Director of Nursing revealed it was the facility's expectation that residents' plan of care include a care plan to address a residents' discharge plans.
Review of Resident 158's clinical record revealed diagnoses that included difficultly walking, muscle weakness, osteoarthritis (degeneration of the joint cartilage and the underlying bone, causes pain and stiffness especially in the hip, knee, and thumb joints), hemiparesis (weakness of one side of the body) of the left (non-dominant side) following Cerebral Infraction (a blockage or narrowing of the arteries in the brain that supply blood and oxygen), and dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning).
Review of Resident 158's March 2019, physician orders revealed an order for House Shake, one time a day, with a start date July 17, 2018.
Review of Resident 158's care plan revealed: a focus area for Nutrition risk related to varied intake, history of significant weight loss; with interventions that included to consume 75-100% nutritional supplement.
During an interview with the Director of Nursing on March 21, 2019, at approximately 11:57 AM it was revealed that the facility only documents that the supplement was accepted.
During an interview with the Nursing Home Administrator on March 21, 2019, at approximately 12:59 PM it was revealed that the care plan should be updated to reflect the house supplement would be offered/accepted and/or consumed.
28 Pa Code 201.25(a) Discharge policy
28 Pa Code 211.11(b)(d) Resident care plan
| ||Plan of Correction - To be completed: 04/26/2019|
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
1. A discharge care plan was created for Resident 77. Resident 158 had the care plan updated for house supplement acceptance.
2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Care Planning QAPI tool a comprehensive audit of residents will be completed by the Interdisciplinary Care Plan Team before the date of compliance 4/26/19.
3. To ensure that the deficient practice does not reoccur, The Administrator or designee will in-service the Social Service staff and the Dietitian on the Focus on the Ftag 656 regulation to ensure a comprehensive plan of care is developed and implemented.
4. Utilizing the Care Planning QAPI tool, the Social Service Coordinator or designee will audit 5% of resident care plans weekly for 4 weeks and monthly for 2 months to ensure a comprehensive plan of care is developed and implemented for discharge planning and supplements. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.
5. Facility alleges substantial compliance on 4/26/19.