|§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 review and interview with staff, it was determined that the facility did not develop a comprehensive care plan related to pressure ulcer care for two of seven records reviewed (Residents R1 and R4).
Review of facility policy titled "Care Plan" dated November 2021 revealed that it is the policy of the facility that care plans are to include "initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social services and PASARR recommendations," and that they "will be updated timely and necessary revisions will be made."
Review of clinical documentation revealed that resident R1 was admitted to the facility on May 11, 2022 with a stage 4 pressure ulcer (which has gone through skin and fat and exposed the muscle or bone) to her sacrum. A nursing note dated May 11, 2022, stated "Sacral wound in place with eschar noted to wound bed." Orders were entered on May 11, 2022 stating "Sacrum every day shift cleanse with NSS, pat dry, apply no sting to periwound," (the area around a wound) "apply medihoney to wound bed, cover with Ca+ alginate," (an absorbent wound dressing which controls fluids and promotes healing) "and foam dressing." The resident was discharged on June 13, 2022. Review of the resident's care plan history revealed that no care plan was developed for the resident's wound care.
Review of clinical documentation revealed that Resident R4 was admitted to the facility on April 1, 2022. Facility acquired stage 3 pressure ulcers (which has gone through the skin and exposed the fat layer) of his left and right buttocks were identified in a wound consult note dated May 4, 2022. Orders were entered on May 4, 2022, stating "B/L" (bilateral- both sides) "buttock every day shift cleanse with NSS, pat dry, apply medihoney to wound bed; then Ca alginate and cover with CDD," (clean dry dressing) "until healed." The resident was discharged on May 30, 2022. Review of the resident's care plan history revealed that no care plan was developed for the resident's wound care.
Interview with Director of Nursing and Nursing Home Administrator on June 30, 2022, at 1400, confirmed that a care plan for wound care for these two residents should have been developed but was not.
28 Pa. Code 211.11(d) Resident care plan.
| ||Plan of Correction - To be completed: 07/04/2022|
1)Resident R1 and R4 suffered no ill effect of the missing care plan because appropriate treatment was taking place. No additional action could be taken at the time of the survey due to both residents being discharged from the facility.
2)Any Resident admitted with a pressure wound are at risk to be affected by the deficient practice. An audit was completed on all residents with a pressure ulcer to make sure all comprehensive care plans are in place.
3)The comprehensive care plan policy was reviewed and updated. All nurses were re-educated on the comprehensive care plan policy with special focus on residents with pressure ulcers.
4)DON or designee will audit care plans of residents with identified wounds to make sure comprehensive care plan is in place weekly x 4 weeks, monthly x4 and then quarterly x 4.