§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 observation, clinical record review and staff and resident interviews, it was determined that the facility failed to develop person-centered care plans that included individual resident needs and preferences for self-administration of medication and potential for pain for two residents out of 13 sampled (Resident 13 and 3).
Findings include:
A review of the clinical record revealed Resident 3 was admitted to the facility December 11, 2023, for orthopedic aftercare. An Nursing Admission Evaluation dated December 11, 2023, revealed the admission diagnosis as failure of recalled total hip arthroplasty hardware.
Hospital discharge instructions dated December 11, 2023, prior to the resident's admission to the skilled nursing facility, indicated that had been hospitalized for a left hip arthroplasty because of a left hip hardware failure.
A Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 18, 2023, revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 15. The MDS assessment noted that the resident has had pain or was hurting in the last 5 days.
A facility pain evaluation dated December 24, 2023, indicated that the resident has experienced pain at the left surgical hip.
Interview with Resident 3, in her room on January 3, 2024, at approximately 10:40 AM, revealed that currently she does experience pain
A review of Resident 3's care plan conducted during the survey ending January 5, 2024, revealed that the resident's comprehensive care plan did not include the resident's potential for pain or actual pain.
Interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of potential for pain, and pain management needs, on Resident 3's care plan.
Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses to have included orthopedic aftercare, pneumonia, and diabetes.
A review of the clinical record indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact).
The resident's care plan indicated that the resident was at risk for complications of blood sugar fluctuations related to diagnosis of diabetes initiated December 20, 2023, with a goal that the resident will not exhibit complications of Diabetes or signs/symptoms of hypoglycemia or hyperglycemia through next review as of the target Date of January 5, 2024. Interventions planned were to administer medications, assess and report to physician signs/symptoms of hypoglycemia or hyperglycemia as indicated by cold, clammy skin; sweating; lethargy; confusion, blood glucose monitoring, monitor lab tests, skin, especially feet, every shift and report any reddened or open areas to physician, and to provide diet per physician orders.
The resident had current physician orders dated December 21, 2023, Lantus (diabetes medication) SoloStar subcutaneous solutions pen-injector 100 Unit/ML (Insulin Glargine), inject 42 unit subcutaneously two times a day for Diabetes Mellitus (DM).
Observation and interview with Resident 13, in his room on January 3, 2024, at approximately 10:33 AM, revealed an opened Lantus Solo Star insulin pen on the resident's bedside table next to his personal items. During the interview with the resident, he stated that staff leaves the insulin pen in his room for him to self-administer his insulin.
A second observation of Resident 13 on January 3, 2024, at approximately 11:13 AM, revealed the Lantus Solo Star insulin pen remained on the resident's bedside table next to his personal items.
A third observation of the resident on January 3, 2024, at approximately 12:00 PM, in the presence of Employee 1 (Registered Nurse) confirmed the Lantus Solo Star insulin pen on the resident's bedside table next to personal items. Employee 1 confirmed that resident 13 does self administer the Lantus insulin. During an interview on January 3, 2024, at approximately 12:05 PM, with employee 1 (RN), a review of resident 13's clinical record confirmed the resident's comprehensive care plan failed to identify the resident's self administration of insulin.
During an interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of medication (Lantus) self administration on Resident 13's care plan.
Refer F554
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (d)(5) Nursing services
| | Plan of Correction - To be completed: 02/14/2024
1. Resident #13 is discharged home. Resident #3's care plan has been updated to address the resident's pain. 2. An audit will be completed on all in-house residents with actual or potential for pain and those that self-administer medication to ensure that a comprehensive care plan is developed and implemented. 3. Staff education will be completed with licensed nursing staff on person centered care planning for pain and self administration of medication. 4. The DON, or designee, will complete audits on residents with potential for or actual pain and those self-administering medications to ensure that a comprehensive care plan is developed and implemented. Results will be reviewed with the QAA committee x 3 months then re-evaluated.
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