§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise care plans for two of six residents reviewed (Residents 4, 5), resulting in Resident 5 experiencing a fall with a fracture.
Findings include:
The facility's policy regarding care plans, dated August 8, 2019, indicated that care plans would include interventions based on the resident's needs and strengths, and would be updated when a change in condition occurred.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 2, 2019, revealed that the resident was understood and could understand; required assistance from two staff for bed mobility, transfers, dressing, toileting, and personal hygiene; and had diagnoses that included dementia (a loss of thinking, remembering, and reasoning skills). The resident's care plan, dated December 20, 2018, revealed that she was at risk for falls and staff were to anticipate and meet her needs. Interventions included using bilateral hand rails to aid in positioning; to educate the resident about safety reminders and what to do if a fall occurs; to encourage/assist the resident to wear appropriate footwear when ambulating (walking) or while sitting in a chair; to have an area that was free of environmental factors; to use assistive devices (walker/wheelchair); that the resident was to be out of bed in an 18 inch hemi-height wheelchair with rear anti-tippers (keeps the chair from tipping backward); and for the resident to transfer with minimal assistance and a wheeled walker.
Resident 5's care plan dated January 18, 2019, revealed that she had actual physical aggression toward staff, wandering behavior, and attempts to self-ambulate and self-transfer. Interventions included discussions with the resident about her behavior; explaining acceptable behaviors versus inappropriate behaviors; minimizing the potential for the resident's disruptive behaviors by offering tasks that divert her attention, such as asking the resident to help fold towels or baby clothes; that the resident enjoyed doing crafts and offering her a simple craft to work on or coloring pages.
A nursing note for Resident 5, dated April 16, 2019, revealed that the resident was continually getting up to ambulate on her own, staff continuously returned her to her wheelchair and reminded her to ask for assistance with any ambulation, and attempted to get her involved in several activities to distract her without any success. A revision to Resident 5's care plan, dated April 18, 2019, revealed that staff were to offer to take the resident for a walk when she attempted to self-ambulate/self-transfer to ensure her safety and reduce self-ambulation/self-transfer attempts. A physical therapy evaluation, dated April 23, 2019, revealed that the resident was referred to physical therapy due to the resident continually getting up to ambulate on her own. The evaluation indicated that there was no appropriate physical therapy intervention at that time and the discharge plan was to remain in the skilled nursing facility with the restorative nursing program.
A nursing note for Resident 5, dated April 30, 2019, revealed that the resident was sitting on the floor on her right hip and leaning on the side of the bed, with her right arm on the bed holding onto the assist bar. The resident was alert, verbal and confused (baseline) and was unable to state what happened. She was last seen by staff approximately fifteen minutes prior to finding her on the floor.
An Interdisciplinary Team progress note for Resident 5, dated May 1, 2019, revealed that the resident's fall from April 30, 2019, was reviewed to identify fall triggers and revise her care plan to reduce falls. The resident had been toileted at 8:00 p.m., and a visual check was completed at 9:30 p.m. with the resident appearing to be sleeping. The resident was found on the floor at 10:00 p.m. when rounds to offer assistance to use the bathroom were completed. The note indicated that the resident was continent at the time of the fall, and the team would continue to attempt to identify all fall triggers with the goal to reduce falls with injury.
However, there was no documented evidence that any new and/or revised interventions to prevent falls and/or injury were initiated following Resident 5's fall on April 30, 2019.
A nursing note for Resident 5, dated June 8, 2019, revealed that the resident was found sitting on the floor on the right side of her bed. She was awake and alert with her baseline confusion and was unable to explain what happened. The resident was noted to have a deformity of the right upper arm, and full range of motion (joint movement) was not able to be performed on that extremity due to the resident's severe pain with movement. The physician was notified and an order was obtained to transfer the resident to the emergency department for x-rays and further evaluation.
A nursing note for Resident 5, dated June 8, 2019, revealed that report from the emergency room indicated that the resident had a fractured humerus (bone in the upper arm) and would be returning with a splint and sling on the right arm.
Interview with the Director of Nursing on December 30, 2019, at 3:08 p.m. confirmed that new and/or revised interventions to prevent falls and/or injury were not initiated for Resident 5 following her fall on April 30, 2019.
A quarterly MDS assessment for Resident 4, dated October 18, 2019, indicated that the resident was cognitively impaired and required assistance with daily care tasks, including ambulation (walking). Physician's orders, dated October 14, 2019, included an order for the resident to ambulate with contact assistance and a wheeled walker.
A nursing note for Resident 4, dated October 13, 2019, revealed that the resident was found sitting on the floor. A nursing note dated October 18, 2019, indicated that a sensor monitor (picks up movement and alarms) was in place.
Observations on December 31, 2019, at 8:15 a.m. and 8:32 a.m. revealed that Resident 4 had a sensor monitor located on the headboard of her bed.
There was no documented evidence that Resident 4's care plan was revised to include the use of a bedside movement sensor monitor.
Interview with the Director of Nursing on December 30, 2019, at 12:00 p.m. confirmed that Resident 4's care plan should have been updated to include the use of a sensor monitor.
42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 6/21/19, 3/22/19, 4/27/18.
28 Pa. Code 211.11(d) Resident care plan.
Previously cited 9/17/19, 6/21/19, 3/22/19, 4/27/18.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/4/19, 9/17/19, 7/26/19, 6/21/19, 5/15/19, 3/22/19, 7/31/18, 4/27/18.
| | Plan of Correction - To be completed: 01/21/2020
Resident R4 care plans have been reviewed and revised.
A care plan review has been conducted on intervention revision as appropriate and that interventions are in place as indicated.
R4 was evaluated by Therapy and identified as independent with transfer status.
Policy and Procedure was reviewed and Interdisciplinary team re-educated regarding the review of incidents and resident change in condition for updates of care plan interventions during clinical start up meeting.
Education will be provided to licensed nursing staff by the Director of Nursing or Designee on F657 with a focus on updating the resident's care plan with appropriate revisions.
Director of Nursing or designee will monitor care plans for timeliness of revisions.
Results of monitoring will be reported to the Quality Assurance Performance Improvement Committee.
Resident R5's care plans have been reviewed and revised.
A care plan review has been conducted on intervention revision as appropriate and that interventions are in place as indicated.
R5's Care plan was revised to include wearing non-skid socks when in bed to assist in preventing future falls.
Policy and Procedures were reviewed and Interdisciplinary team re-educated regarding the review of incidents and resident change in condition for updates of care plan interventions during clinical start up meeting.
Education will be provided to licensed nursing staff by the Director of Nursing or Designee on F657 with a focus on updating the resident's care plan with appropriate revisions.
Director of Nursing or designee will monitor care plans for timeliness of revisions.
Results of monitoring will be reported to the Quality Assurance Performance Improvement Committee.
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