|§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, staff interview, and observation, it was determined that the facility failed to implement and develop a care plan for one of five sampled residents. (Resident 76)
Clinical record review revealed that Resident 76 had diagnoses that included respiratory failure and congestive heart failure. On August 15, 2019, the physician ordered oxygen via nasal cannula at two liters per minute continous for the resident. Review of the physician's note dated November 19, 2019, revealed that the resident "continued to raise his oxygen above ordered levels." A social services note dated December 4, 2019, revealed that Resident 76 was moved to a room closer to the nurses station for increased supervision as he continues to unhook his oxygen.
Observations on December 13, 2019, at 10:40 a.m. revealed Resident 76 in his room with his oxygen at five liters per minute via nasal cannula. At 11:00 a.m. through 11:15 a.m, the resident was observed in his room manipulating his oxygen concentrator. In an interview on December 13, 2019, at 10:50 a.m., RN1 stated that Resident 76 continuously manipulates his oxygen and was noncompliant with education regarding appropriate oxygen rate. There was no care plan developed to address Resident 76's noncompliance of his physician ordered oxygen with interventions and monitoring of his respiratory status.
In an interview on December 13, 2019, at 1:00 p.m., the Nursing Home Administrator confirmed that there was no care plan with interventions developed for Resident 76's noncompliance with his physician ordered oxygen.
28 Pa. Code 211.11(d) Resident care plan.
| ||Plan of Correction - To be completed: 12/23/2019|
Preparation and Submission of this Plan of Correction is required by state and federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
1). Resident 76 has had his care plan updated to reflect noncompliant behavior.
2). To identify other residents with the potential to be affected, an audit was completed to ensure residents with noncompliant behaviors have care plans in place.
3). To prevent this from reoccurring, the Interdisciplinary team has been reeducated to update the care plans with any changes in behaviors.
4).To ensure ongoing compliance, DON/designee will audit behavior care plans weekly for four weeks and quarterly and as needed thereafter.
5). Results of audits will be brought to the QAPI meeting.