|§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 clinical records and staff interview, it was determined that the facility failed to ensure that the person-center comprehensive care plan accurately reflected the resident's specific individualized needs and current approaches for one out of three residents reviewed (Resident 13).
A review of the clinical record of Resident 13 revealed that the resident had diagnoses that included depression, chronic pain, diabetes and osteomyelitis (an infection of the bone).
An annual Minimum Data Set assessment (MDS - a federally mandated standardized process conducted periodically to plan resident care) dated October 10, 2019, revealed that the resident's cognition was intact.
A review of a nurse's note dated November 15, 2019, at 2:01 p.m. indicated that the "CRNP (certified registered nurse practitioner) was made aware that resident is not capable of independent self administation of medication due to safety risk and noted hiding of pills; new order now, resident may go out on TLP without medications; resident made aware and voiced understanding."
A physician's order dated November 15, 2019, indicated that the resident may go out on TL (therapeutic leave) and no meds (medications) to go with resident.
A review of the resident's current care plan dated October 10, 2016, revealed that the resident desired to participate in therapeutic leave. The goal was to facilitate a safe experience out of the facility. Interventions planned were a physician's order to allow therapeutic leave, a determination of the length of leave time and, a determination of the medications to be adminstered while out of facility.
However, at the time of the survey ending December 30, 2019, Resident 13's comprehensive care plan specific to therapeutic leave, did not reflect the physician order to not include any medications when the resident was out the facility.
During an interview with the director of nursing and assistant nursing director on December 30, 2019, at approximately 1:20 p.m., they were unable to explain why Resident 13's current comprehensive care plan did not reflect the resident's current status and needs when on therapeutic leave.
28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services.
Previously cited 11/8/19
28 Pa. Code 211.11(d) Resident care plan.
| ||Plan of Correction - To be completed: 01/16/2020|
1. Resident 13's comprehensive care plan has been revised to reflect his current status and needs when on therapeutic leave (TL).
2. An audit will be completed for residents who have physician orders to participate in TL, to ensure that their comprehensive plan of care reflects their current status and needs when on leave from the facility.
3. Professional nursing staff will be educated to develop a comprehensive care plan to reflect a resident's current status and needs when on therapeutic leave.
4. Audits will be completed by ADON, or designee, five times a week for residents with new physician orders to participate in TL, to ensure that their comprehensive plan of care reflects their current status and needs when on leave from the facility. Results of these audits will be reviewed by the Quality Assurance Committee for one month and re-evaluated.