§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 a review of clinical records, and staff interview, it was determined the facility failed to address a resident's skin condition on the comprehensive care plan for one out of 16 sampled residents (Resident 23).
Findings include:
A review of the clinical record revealed Resident 23 was admitted to the facility on May 15, 2023, with diagnoses which include congestive heart failure, cerebrovascular accident (CVA- stroke, interruption in the flow of blood to cells in the brain), and rheumatoid arthritis.
A physician order dated June 27, 2024, noted an order to apply Zinc to buttocks every shift for skin protectant/moisture barrier.
A wound progress note dated August 1, 2024, indicated the resident's sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis) was assessed and was noted to have MASD (Moisture-associated skin damage caused by prolonged exposure to various sources of moisture, including urine or stool, or perspiration) of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants measuring 3 cm (centimeters) x 5 cm x 0.1 cm. The area is open with light serous exudate (clear, thin, watery plasma that is a normal part of wound healing). The treatment plan was to apply Zinc ointment twice daily for 30 days. Further recommendations included, limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able.
A wound progress note dated August 8, 2024, indicated that the MASD on the resident's sacrum now measures 3 cm x 4 cm x 0.1 cm. the area is open with light serous exudate and noted to be improved. The dressing treatment plan was to continue to apply Zinc ointment twice daily for 30 days. Further the recommendations were to continue to limit sitting to 60 minutes, off-load wound, reposition per facility protocol, turn side to side in bed every one to two hours if able.
A review of Resident 23's comprehensive plan of care (a tool used to organize aspects of patient care) conducted during the survey on August 14, 2024, revealed the resident's care plan did not address the resident's moisture associated skin disorder, treatment, and specific interventions to prevent recurrence.
Interview with the Director of Nursing on August 14, 2024, at approximately 10:30 AM confirmed the resident received treatment for the MASD, and the MASD was not addressed on the resident's care plan along with preventative measures to address the resident's identified risk factors to promote optimal healing and prevent recurrence.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
| | Plan of Correction - To be completed: 09/18/2024
1. The comprehensive care plan for Resident 23 was updated to include the resident's MASD diagnosis, the current treatment plan, and specific interventions, including the application of Zinc ointment, repositioning schedules, off-loading pressure, and limiting sitting time. A care conference was held with the interdisciplinary team to review and update the care plan and ensure interventions are appropriate to meet the needs of the resident.
2. DON/Designee will audit current residents with skin conditions to ensure that their care plans are accurate and reflect their diagnoses, treatments, and preventive interventions. The facility implemented a weekly interdisciplinary team (IDT) review of resident care plans, focusing on residents with high-risk conditions such as skin issues. During these reviews, the team will ensure care plans are comprehensive, up-to-date, and include specific interventions for identified risks.
3. The NHA/designee will educate the IDT on the weekly skin risk meeting implemented which will review resident care plans, focusing on residents with high-risk conditions such as skin issues. During these reviews, the team will be educated to ensure care plans are comprehensive, up-to-date, and include specific interventions for identified risks. The DON/designee will educate the licensed nursing staff on care planning and the importance updating comprehensive care plans to include aspects of resident care, particularly in response to new orders, treatments, or changes in condition, and interventions and preventative measures.
4. The DON or designee will conduct weekly audits to ensure weekly risk meetings are completed and that residents' care plans are updated reflecting any skin conditions and or other high-risk factors as well as appropriate interventions to meet the plan of care provided. Audits will be completed weekly x4 weeks than monthly x 2 months. Audits will be reviewed in QAPI.
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