§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
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Observations:
Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of seven residents (Resident R1).
Findings include:
Review of the facility policy "Care Plans. Comprehensive Person-Centered", dated 7/1/26, indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.
When possible , interventions address the underlying source(s) of the problem area(s), not just the symptoms or triggers.
Review of Resident R1's admission record indicated she was originally admitted on 1/5/24.
Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) assessment dated 8/1/26, indicated diagnoses of dementia (decline in cognitive function), anxiety and frontotemporal neurocognitive disorder (brain disease that mainly affects the frontal and temporal lobes of the brain).
Review of facility provided documentation indicated Resident R1 fell on 9/11/26.
Review of Resident R1's care plan dated 5/14/26, failed to include any revision that resident had a fall.
During an interview on 9/24/26, at 1:45 p.m. the Director of Nursing confirmed that the care plan was not updated to include Resident R1's fall and confirmed that the facility failed to make certain a resident had an updated, person-centered care plan individualized to each specific resident's needs for one of seven residents (Resident R1).
28 Pa. Code 201.24(e)(1)(5) Admissions Policy
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 11/09/2026
1. Resident R1 care plan was updated to reflect an unwitnessed fall.
2. A 30 day look back will be completed of incident reports to identify any resident who has had a fall to validate the care plan was reviewed and revised in a timely manner.
3. DON/designee to educate RNAC on care plan policy and updating care plans of residents who have a fall.
4. DON/designee to audit care plans of residents who have had a fall weekly x 2 weeks, then monthly x 2 months to validate the fall care plans have been updated timely to reflect residents current condition.
5. All results to be submitted to QAPI for review and approval.
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