§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 facility policy and clinical records, and staff interview, it was determined that the facility failed to develop and implement a resident centered comprehensive care plan for one of 22 residents reviewed (Resident R58).
Findings include:
A facility policy entitled, "Comprehensive Person-Centered Car Planning" dated 1/10/24, indicated that a comprehensive person-centered care plan including necessary and appropriate care, attending physicians ordered, services and accommodation of resident needs and preferences for the resident to attain or maintain the highest practicable physical, mental, and psychological well-being will be established within 21 days of admission.
Resident R58's clinical record revealed an admission date of 3/06/24, with diagnoses that included pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), arthritis, lower back pain, and restless leg syndrome.
Resident R58's clinical record included physician's orders dated: 3/06/24, to give 650 milligrams (mg) of acetaminophen every six hours as needed for pain; 3/14/24, to give 650 mg of acetaminophen at bedtime for pain management; 4/01/24, to give 650 mg three times a day for back pain and 650 mg as needed for back pain once daily; and current physician's orders dated 5/09/24, to give 650 mg of Tylenol three times a day for other low back pain, and give 650 mg of Tylenol every four hours as needed for pain, may have one additional dose four plus hours after nine p.m.
Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain.
During an interview on 6/05/24, at 10:47 a.m. the Director of Nursing confirmed that Resident R58's clinical record lacked evidence of a comprehensive person-centered care plan for pain management.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 07/10/2024
1.Resident R58's care plan amended on 06/06/2024 to include a comprehensive person-centered care plan for pain.
2.Education to be provided to RNACs regarding person centered-care plan for pain 06/26/2024 and 06/27/2024.
3.Director of nursing and RNAC reviewed care plans of all current residents prescribed pain medications to ensure person centered care plan for pain was present.
4.Director of Nursing or designee will complete an audit of 10% of the resident population, to ensure resident care plans include pain management when applicable. Audits will be completed weekly x 4 weeks, monthly x 3 months, and quarterly x 1. Audits will be reviewed at monthly Quality Assurance meetings.
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