|§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 observation, a review of clinical records, and staff interview, it was determined that the facility failed to develop and implement a person-centered plan to address a resident's oxygen use for one of 30 residents reviewed (Resident 41).
Review of clinical records revealed that Resident R41 was admitted to the facility on December 29, 2020, with a diagnosis to include Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow) and Asthma (a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). The resident had an admission order and an active order as of March 15, 2021, for oxygen at two liters per minute via a nasal cannula (device used to deliver supplemental oxygen) as needed to maintain a saturation level greater than 91%.
Observation on March 16, 2021, at 1030 a.m. revealed Resident R41 was sitting in her wheelchair by her room with her oxygen nasal cannula hanging down by her neck, that was not connected to her nose, as ordered by her physician. Employee E3, Activities staff, assisted the resident's oxygen back onto her nose and the resident stated the oxygen was uncomfortable. Employee E3, Activities staff, stated she would inform the nursing staff.
Review Resident R41's clinical record nursing note dated March 3, 2021, revealed : " ... on oxygen 2 lt/min [liters / minute] via nasal canula on resident takes it off at times explain and educated resident for need of oxygen on ..."
Further review of of Resident R41's clinical record revealed no comprehensive care plan had been developed or implemented for the care and maintenance of the the oxygen use.
An interview on March 17, 2021, at 2:45 p.m. with the administrator confirmed that Resident R41 had an order for oxygen use and the facility did not develop or implement a comprehensive care plan for the care and maintenance of oxygen usage.
28 Pa Code 211.11(d) Resident care plan
28 Pa Code 211.12 (c)(d)(3)(5)Nursing Services
| ||Plan of Correction - To be completed: 04/14/2021|
1. Facility reviewed and updated accordingly the care plan for resident R41 in relation to the care and maintenance of oxygen use.
2. Care Plans for residents with oxygen orders will be reviewed to ensure that their care plan reflects the care and maintenance of their oxygen use.
3. Licensed Nurses will be re-educated by the Director of Nursing/Designee to ensure that nurses are implementing resident care plans that includes the care and maintenance of oxygen use for resident's who have physician orders for oxygen.
4. Random Audits will be completed weekly x4 then monthly x3 by the Director of Nursing/Designee to ensure that residents with a physician order for oxygen are reflected on their care plan.
5. Audits will be discussed and reviewed by the facility QAPI committee meeting x3 to ensure compliance.