§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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
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Observations:
Based on clinical record review and staff interviews, it was determined the facility failed to develop a person-centered care plan that included individual behavioral management for one resident out of 9 sampled (Resident 1).
Findings include:
A review of the clinical record revealed Resident 1 was admitted to the facility on April 13, 2025, with diagnoses to include alcohol abuse, adjustment disorder, depression and anxiety and a below the knee amputation (surgical removal of leg below the knee).
A review of an admission Minimum Data Set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 20, 2025 revealed him to be moderately, cognitively impaired with a BIMS assessment score of 10 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 8-12 indicates moderate cognitive impairment) had verbal behaviors towards others, required staff assistance with activities of daily living and utilized a wheelchair for ambulation.
Nursing progress notes from the date of admission reflected an ongoing pattern of behavioral concerns. Documentation dated April 15, 2025, at 2:58 PM indicated that Resident 1 was sent to the emergency room after verbally threatening his roommate over control of the television. Additional progress notes documented that Resident 1 continued to exhibit escalating verbal and physical behaviors. On April 20, 2025, at 9:02 PM, Resident 1 reportedly told a nurse aide that he "was going to smash the glasses off her face and wished he had a gun to shoot her."
On April 28, 2025, at 1:15 PM, nursing and therapy staff observed Resident 1 and Resident 2, both seated in wheelchairs in Resident 1's room. Resident 1 was witnessed holding Resident 2's penis and moving it in an up-and-down motion. Resident 2 was immediately removed from the room.
Further documentation dated May 1, 2025, at 7:25 PM noted that Resident 1 continued to be monitored for "behaviors." The entry stated that staff had to repeatedly remove Resident 1 from the lobby area due to his close proximity to Resident 2 and attempts by Resident 2 to inappropriately touch Resident 1.
A review of Resident 2's clinical record revealed he was admitted on October 30, 2024, with diagnoses including cerebral infarction (stroke), anxiety, and mild cognitive impairment. A Quarterly MDS assessment dated February 6, 2025, revealed Resident 2 had a BIMS score of 9 (indicating mild cognitive impairment), exhibited no behavioral symptoms, and used a wheelchair for ambulation.
A review of Resident 1's care plan revealed an entry dated April 16, 2025, addressing verbal aggression toward others. Another care plan problem initiated on April 29, 2025, stated the resident "exhibits desire to be sexually expressive but verbally denies same." However, there was no evidence at the time of survey that the care plan had been revised to reflect the ongoing behavioral incidents involving Resident 2 or to implement individualized interventions to mitigate risk and protect resident safety.
During an interview on May 13, 2025, at approximately 1:30 PM, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to ensure Resident 1's care plan was updated to address ongoing behavioral incidents and that the care plan did not adequately reflect person-centered approaches or risk management strategies related to his interactions with Resident 2.
28 Pa. Code 211.12 (d)(5) Nursing services.
| | Plan of Correction - To be completed: 05/27/2025
1. Resident 1 and 2's care plans updated.
2. An audit was completed on resident's comprehensive care plans to ensure individual behavioral management was included and updated if indicated
3. DON/designee to re-educate licensed staff on care plan policy.
4. DON/designee to audit 5 Resident's comprehensive behavior care plans weekly X 4 and monthly X 2 to confirm compliance. Results will be brought to the monthly QAPI meeting.
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