§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, a review of clinical records, review of facility documentation and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plans regarding preventing a reinfestation of lice for one of ten residents reviewed. (Resident R2).
Findings include:
Review of clinical records revealed that Resident R2 was admitted to the facility on June 9, 2022, with diagnosis to include bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
Further review of Resident R2's clinical record indicated that on May 31, 2024, he returned to the facility after a visit with his sister, and the next day was observed to have lice in his scalp and received treatment to himself, his roommate and there room and clothing. Further review revealed a similar incident that happened on April 16, 2024, when his sister brought in clothing for him which were infested with lice and resulted with the same treatments.
Review of Resident R2's care plan revealed no care plan to prevent further infestations of lice related to family visits or bringing in infested items into the facility.
An interview on June 11, 2024, at 11:25 a.m. with the LNAC (Licensed Nurse Assessment Coordinator) confirmed that there was no care plan for preventing a lice infestation related to visits with family or items brought in to the facility, and she also noted that it is the unit manager who generally writes these care plans.
An interview on June 11, 2024, at 12:20 p.m. with the Director of Nursing confirmed that the resident did not have a comprehensive care plan regarding preventing another lice infestation.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 07/09/2024
R2's Care Plan has been updated to reflect prevention of reindentation of lice.
All resident care plans reviewed and updated to ensure that they are comprehensive
Unit Managers or designee will continue to Audit Care Plans (60 care plans) Weekly times 2 weeks to ensure that they are comprehensive
Unit Managers or designee will Audit ALL Care Plans Quarterly thereafter to ensure that they are comprehensive.
Staff educator will in-service unit mangers on the importance of ensuring inclusive / comprehensive care plans.
Results will be reported in monthly QAPI.
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