§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 clinical records and staff interviews, it was determined that the facility failed to implement care and services identified on a comprehensive care plan regarding provision of care for activities of daily living (ADL) for one of 17 residents reviewed (Resident R41).
Findings include:
Review of Resident R41's clinical record revealed an admission date 10/2/2020, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), history of seizures, vascular dementia (brain damage cause by multiple strokes), history of transient ischemic attacks and cerebral infarction (temporary blockage of blood flow to the brain), altered mental status, other abnormalities of gait and mobility, and type one diabetes mellitus (a condition where the pancreas makes little to no insulin, leading to high blood sugar levels).
Review of R41's Minimum Data Set (MDS-a periodic assessment of resident care needs) Assessment Section GG Functional Abilities and Goals last updated 2/21/2024, revealed that Section GG0130 Self-care revealed Shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self, identified that Resident R41 required partial/moderate assistance; Section GG0170 FF: tub/shower transfer: the ability to get in and out of a tub/shower revealed that Resident R41 required partial/moderate assistance.
Review of Resident R41's ADL related care plan originally dated 10/12/2020 and last reviewed 3/19/2024, revealed "resident has an ADL self-care performance deficit." Bathing required an assist of one staff member with bathing/showering.
Review of an incident regarding Resident R41 revealed he/she was left unattended in the tub/shower area on 4/10/24, with subsequent fall with injury based on a physician's order dated 2/12/2021 for "transfers independently."
During an interview on 6/6/2024, at approximately 3:30 p.m. with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the inconsistencies in Resident R41's clinical record and that the ADL care plan was not implemented accurately.
Interviews conducted with facility staff members on 6/7/2024, between 10:25 am. and 10:40 a.m. revealed that prior to showering residents, the resident care plan for ADL's is to be reviewed to determine proper transfer/assistance level information to ensure resident safety.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 07/12/2024
"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
F656
Resident R41's care plan was corrected to reflect the accurate assistance with bathing/showering.
Facility nursing staff will complete an audit on all current residents to ensure bathing/shower assistance is accurately noted on resident's ADL care plan.
Interdisciplinary team with responsibility to complete care plans will be re-educated by Regional MDS Nurse/designee on the need to Care Plan bathing/showering to meet regulations.
The MDS Nurse/designee will audit five resident individualized care plans weekly for four weeks and monthly for two months to ensure bathing/showering interventions are current to resident needs.
Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.
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