§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 reviews and resident and staff interviews, it was determined that the facility failed to implement the comprehensive care plan interventions to prevent pressure ulcer healing and discomfort for one of three resident reviewed (Resident R1).
Findings include:
Review of R1's records revealed a care plan dated December 24, 2023, documenting the resident has a pressure ulcer or has potential for pressure ulcer development related to disease process, immobility, sacral wound.
Interventions documented the need for staff to elevate/offload heels when in bed as tolerated using pillows, bootie, heel protectors or heel cushions.
Observation of R1 on January 17, 2024, at 12:30 p.m., revealed the resident lying in bed with resident's heels contacting a pillow. Observations also revealed resident wearing socks, with no heel booties, heel protectors or heel cushions. Further observation of resident's room revealed heel booties sitting on air conditioner unit.
Interview on January 17, 2024, at 12:35 p.m., with E3 revealed that R1 often refused to wear the heel booties because they were painful.
Observation of R1 on January 17, 2024, at 1:50 p.m., revealed that staff had put the heel booties on the resident, although it was known to staff that the resident did not like to wear them because they were painful. Interview with the resident confirmed they were painful, and the resident did not want to wear them.
Interview conducted on January 17, 2024, at approximately 3:30 p.m., with Nursing Home Administrator and Director of nursing, confirmed Resident R1 was care planned for pressure ulcers with interventions to include elevate/offload heels when in bed as tolerated using pillows, heel booties, heel protectors or heel cushions but the interventions were not implemented, as noted by observation.
The facility failed to implement Resident R1's comprehensive care plan which included interventions to offload heels to prevent pressure wounds.
28 Pa Code 211.10(d) Resident care policies
28 Pa Code 211.11(d) Resident care plan
28 Pa. Code 211.12(c) Nursing services
| | Plan of Correction - To be completed: 02/12/2024
· R1's pillow was repositioned to offload her heels.
· The Director of Nursing / Designee completed an audit of residents who are care planned with interventions to elevate/ offload heels. No additional variances were identified.
· The Director of Nursing/ Designee re- educated nursing staff on elevating/ offloading heels as per care plan.
· The Administrator / Designee will complete an audit of residents who are care planned with interventions to elevate/ offload heels 5 times a week for 2 weeks, then weekly for 3 weeks, then monthly for 2 months. Results from the audits will be submitted to the quality assurance performance improvement committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.
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