§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.
|
Observations:
Based on review of facility policy, clinical record review, resident observation, and staff interview, it was determined that the facility failed to implement a comprehensive person-centered care plan intervention intended to promote resident safety by failing to ensure an electronic wandering safety device was in place for one of 12 residents reviewed (Resident 9).
Findings include:
A review of the facility policy titled "Care Plan Process," last reviewed July 1, 2026, indicated the facility will promote coordinated interdisciplinary care through an individualized plan of care based on assessment, planning, treatment, services, and interventions. The policy indicated care will be complete, current, realistic, time-specific, and appropriate to each resident's individual needs.
Clinical record review revealed Resident 9 was admitted to the facility on February 28, 2023, with diagnoses that included traumatic brain injury (damage to the brain caused by a sudden blow, jolt, or other injury to the head).
Review of Resident 9's comprehensive care plan revealed a care plan initiated October 3, 2024, and most recently revised November 18, 2025, identifying Resident 9 as being at risk for wandering. The care plan established a goal for Resident 9 to remain safe and not leave the facility unattended.
The care plan included an intervention, initiated October 3, 2024, and most recently revised February 4, 2025, directing staff to maintain a Wander Guard attached to Resident 9's chair.
A Wander Guard is an electronic safety device used to alert staff when a resident who is at risk for wandering approaches a monitored area or exit.
Observation on August 4, 2026, at 11:28 A.M. revealed Resident 9 seated in the resident's Broda chair (specialized supportive positioning and mobility chair) in a community room in the presence of two activity staff members. The Wander Guard identified in Resident 9's comprehensive care plan was not attached to the Broda chair. The two activity staff members checked Resident 9, including the resident's ankles, and were unable to locate the Wander Guard on the resident or the chair.
During an interview on August 5, 2026, at 11:30 P.M., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident 9's comprehensive care plan directed staff to maintain a Wander Guard attached to the resident's chair and confirmed that the care-planned safety intervention was not implemented as directed.
28 Pa Code 211.10 (c)(d) Resident care policies.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 09/21/2026
1. Corrective Action for Resident 9
Resident 9's elopement risk and current safety needs will be reassessed by safety/investigation coordinator. The care plan was updated as appropriate.
2. Identification of Other Residents
The Safety/Investigation Coordinator will identify residents with wandering/elopement safety interventions and audit their care plans to verify that ordered or care-planned electronic wandering devices are in place and functioning. Identified concerns will be corrected immediately.
3. Systemic Changes
Licensed nurses, CNAs, activity staff, and other appropriate direct-care staff will be re-educated on implementing resident-specific care plan interventions, including wandering/elopement precautions. Staff will be instructed to verify required safety devices are present and functioning and to immediately report missing or malfunctioning devices to the nurse.
4. Monitoring
The safety/investigation coordinator/designee will audit residents with wandering/elopement interventions 5 times weekly for 4 weeks, then weekly for 8 weeks to verify care-planned safety interventions are implemented. Identified concerns will be corrected immediately, with staff re-education as indicated. Results will be reviewed through the facility's QAPI process.
|
|
