§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.
|
Observations:
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to implement care-planned interventions for dining for one of seven residents reviewed (Resident 1).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 13, 2019, indicated that the resident had moderately impaired cognition, required extensive assistance with daily care activities, including eating, and had diagnoses that included dementia (loss of cognitive function). The resident's care plan, dated May 3, 2019, indicated that the resident was to have one bowl, one utensil, and one drink at a time for all meals.
A nutrition note for Resident 1, dated May 3, 2019, revealed that the resident had a weight loss of 9 percent in 3 months and an 11.5 percent loss in 5 months, and the resident's weight was stable for one month. The resident was able to feed himself with one individual bowl and one utensil at a time. A nutrition note, dated July 19, 2019, revealed that the resident was able to feed himself using individual bowls, and at other times staff assisted with meals.
Observations on September 30, 2019, at 6:50 p.m. revealed that Nurse Aide 2 provided Resident 1 his meal tray and he was given a bowl of beans, a bowl of fruit, a hot dog, a carton of chocolate milk, a cup of iced tea, a styrofoam cup of water with a straw, and a fork, knife, and spoon. The dietary slip only indicated that his food was to be in individual bowls.
Interview with Registered Nurse 1 on September 30, 2019, at 7:09 p.m. confirmed that Resident 1 should have been given only one bowl, one utensil, and one drink at a time, as care planned.
42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.
Previously cited 6/13/19.
28 Pa. Code 211.11(d) Resident care plan.
Previously cited 6/13/19.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/13/19.
| | Plan of Correction - To be completed: 11/04/2019
1.The Certified Nursing Assistant received education to follow cardex(information that the care nurses use to direct their care). A new evaluation completed for self-feeding abilities.
2.A review of all residents with meal adaptive equipment will be completed to assure recommendations are reflected on the cardex and care-plan.
3. Whole house education to be completed on following cardex. New employees and Agency staff will be included in this education.
4.The designee will audit all new meal adaptive equipment recommendations to assure cardex and care plan are reflected. Audits will be completed weekly times 4 and them monthly x 2.
.Will review at Quality Assurance Performance Improvement, monthly.
|
|