§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 review of clinical records and facility provided documentation, it was determined facility failed to develop a care plan related to urinary track infection for one of nine residents reviewed (Resident R1)
Findings include:
Review of facility policy 'Care Planning - Interdisciplinary Team,' revised March 2022, indicates that "comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team."
Review of Resident R1's electronic medication administration record (e-MAR), revealed physician order for Bactrim DS oral tablet 800-160 milligrams (mg) every 12 hours for urinary tract infection (UTI), for 5 days, starting March 6, 2025.
Further review of Resident R1's e-MAR, revealed a physician order for Ciprofloxacin HCL oral tablet 250 mg to administer one tablet every 12 hours for UTI for three days, starting March 7, 2025.
Review of incident report, completed on March 18, 2025, indicated that Resident R1 had a change of mental status due to positive UTI.
Review of Resident R1's nursing note, dated March 7, 2025, at 11:50 am, indicated that the resident was treated for UTI.
Review of Resident R1's care plan revealed no evidence of goals or interventions related to UTI; finding confirmed with facility's director of nursing and administrator.
28 Pa Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 04/30/2025
1. R1 care plan reflects her needs. R1 is no longer on antibiotic for UTI.
2. Current residents who are on antibiotics will be checked to ensure antibiotics are careplanned.
3.Facility licensed staff will be in-serviced on ensuring antibiotics use is careplanned.
4. NHA or designee will conduct weekly audits to ensure residents who receive antibiotics are careplanned. Results of audits will be shared with the QAA committee and the committee will determine need for further audits.
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