|§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.
Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to implement care plan interventions for dining for one of 10 residents reviewed (Resident 5).
An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 31, 2019, revealed that the resident was usually understood, could usually understand, required supervision after set-up for eating, and had medical diagnoses that included dementia (decline in memory and thinking skills) and dysphasia (difficulty swallowing). The resident's care plan, dated May 29, 2019, revealed that he needed a mechanically altered diet due to dysphagia, that he did well with his meals with the other residents in the Memory Impaired Unit dining area, and that he needed assistance, encouragement and monitored for impulsivity. A care plan dated August 9, 2019, revealed that the resident requires 100 percent supervision for all meals by one staff.
Physician's orders from Resident 5's previous facility, dated March 17, 2019, included an order for the resident to be on a regular mechanical soft diet with one-to-one supervision to decrease impulsive eating. A medical nutrition data collection assessment, dated May 29, 2019, revealed that speech pathology noted impulsivity and the need for supervision with meals.
A restorative registered nurse note for Resident 5, dated August 29, 2019, revealed that a quarterly review of the resident's restorative nursing program was completed and the resident continued on the restorative nursing program for dining. At times he was impulsive and required supervision with all of his meals. He may feed self; however, he must have a staff member with him at all times to cue him for safe swallowing strategies.
Observations during the supper meal on the Memory Impaired Unit on September 17, 2019, at 5:08 p.m. revealed that Resident 5 was brought from his room and placed at the dining table. At 5:13 p.m. another male resident sitting at the same table was served his meal. At 5:19 p.m., Resident 5 was served his meal and began feeding himself. The staff member who delivered Resident 5's meal tray left and continued to serve other residents their meal trays, as did the other staff members assigned to the Memory Impaired Unit. At 5:24 p.m. the other male resident sitting at the same table took Resident 5's small bowl containing pureed peaches and began to eat them. The other male resident then took a small glass containing a thickened red-colored juice belonging to Resident 5 and began to eat it. At 5:38 p.m. Resident 5 backed himself away from the table. During the observations, there were no staff members directly supervising Resident 5 while he was eating his meal.
Interview with the Director of Nursing on September 17, 2019, at 8:20 p.m. confirmed that Resident 5's care plan indicated that he required 100 percent supervision by one staff for all meals. She indicated that 100 percent supervision would be when the resident requests to eat in his room, and that when eating in the dining room it would involved general observations by staff.
28 Pa. Code 211.11(d) Resident care plan.
Previously cited 6/21/19, 3/22/19.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/26/19, 6/21/19, 5/15/19, 3/22/19.
| ||Plan of Correction - To be completed: 10/11/2019|
Restorative dining program was initiated for Resident 5. Resident 5 will be supervised for meals at the restorative dining table. Resident 5's care plan has been updated to reflect this change.
An audit was performed that identified 6 other residents affected. These residents have also been included in the supervised restorative dining program.
nursing staff educated by Director of Nursing designee regarding supervised restorative dining process. New and agency personnel will be educated on policy by the Director of Nursing designee.
Audits of residents included in the restorative dining program will be conducted by Director of Nursing Designee daily for 3 weeks, weekly for 3 weeks and monthly for 2 months.
Results of audits will be reviewed during monthly Quality Assurance Process Improvement meetings.