§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 clinical record review and interviews with staff, it was determined that the facility failed to develop a comprehensive care plan related to restlessness, scoot chair use, restraints, or bed rails for Resident R1 which resulted in harm to Resident R1 by being tied to a scoot chair and sustaining reddened area on abdomen.
Findings include:
Review of Resident R1's quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident R1, dated December 19, 2023, revealed the resident was severely cognitively impaired, unable to make his/her needs known, required extensive assistance for care activities, incontinent of bowel/bladder, and exhibited inattentive behaviors during the assessment period.
Review of Resident R1's clinical record revealed a progress note date December 26, 2023, at 11:01 pm, noting "resident awakened approximately 9:00 pm. Resident continues to try to get up and walk around, Resident has to be redirected several times, but behaviors continue."
Review of Resident R1's clinical record revealed progress note dated December 27, 2023, at 1:45 pm, noting "received resident sitting in front of common area, very restless and anxious. Received PRN [as needed] 0.5 mg Lorazepam tab at 11:01 pm, prior shift ineffective. Interventions toileting, giving snacks/treats and drinks ineffective."
Further review of Resident R1's clinical record revealed a progress note dated December 28, 2023, at 11:41 pm, indicating "during the beginning of shift resident was noted to be extremely restless and fidgety. Visibly tired and shows signs and symptoms of pain and discomfort. Noted to not be comfortable. Redirection, toileting, snack, and fluids provided with unsuccessful outcomes."
Additional review of Resident R1's clinical record revealed a late entry behavior note for 11pm-7 am shift of December 27, 2023, into December 28, 2023, dated December 28, 2023, at 11:41, indicating "resident was awake and extremely restless throughout the shift. Redirection and interventions were all ineffective."
Review of Resident R1's clinical record revealed progress noted dated December 29, 2023, at 9:53 pm, noted "resident awaken around 9:00 pm, and got out of bed and began walking around room. Roommate rang call light to alert staff and resident removed from the bedroom and placed in wheelchair. Resident toileted and placed back into wheelchair. Continued to be restless and grabbing at anyone and anything. Given PRN [as needed] Morphine which had little success."
Continued review of Resident R1's clinical record revealed a progress note dated December 30, 2023, at 2:27 pm, indicating "the resident woken up for lunch and was observed by this nurse trying to get out of bed, leaning over bed as if to fall. This nurse assisted resident to wheelchair. Fed lunch by this nurse, consumed 100%, During lunch resident restless/anxious unable to sit still or be redirected."
Review of Resident R1's records revealed a fall risk care plan dated December 27, 2021, indicating Resident R1 was at moderate risk for falls. One of the interventions, dated October 10, 2023, indicated staff should monitor resident closely after dinner for signs of fatigue such as gait, slower, more unsteady, assist to bed for rest period or chair for rest period if noted.
Further review of Resident R1's records revealed a care plan dated December 27, 2021, documenting Resident R1 as a wanderer relative to impaired safety awareness. One of the interventions dated December 27, 2021, noted staff should distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. Resident prefers religious activities and music (jazz, gospel, Motown). One revised intervention dated June 28,2023 was observed noting staff should redirect resident to his/her own bed if located in a peer's bed. Encourage rest periods throughout the day, especially in the afternoons.
Review facility documentation including a witness statement from Nurse Assistant (Employee E3) dated December 29, 2023, revealed non licensed Employee E3 observed Resident R1 tied to a chair at the waist with fleece pajama pants, preventing his/her ability to move or stand up.
Review of facility documentation including a witness statement from a Registered Nurse, (Employee E4), dated December 30, 2023, revealed that he/she received a call from Employee E3 to come to the floor as it was urgent. Upon arrival on the unit, he/she was asked to observe Resident R1, who was in the bathroom. Licensed Practical Nurse (Employee E5) stated that Resident R1 was found tied to the scoot chair with a pair of fleece pajamas around her trunk/abdominal region. Per Supervisor, Employee E5 stated "I immediately removed the pajama pants due to red mark noted.' Upon assessment, red mark was resolved, and no other injury noted."
Review of facility records revealed an occupational therapy treatment encounter note dated January 4, 2024, documenting resident was referred for skilled OT evaluation for concave mattress, (bed positioning), and scoot chair (out of bed positioning), and bed rail assessment per [Hospice provider]. Scoot chair with resident's name given to resident. Resident transferred to scoot chair with moderate assist of two persons. Resident exhibited optimal posture in the scoot chair. New order for concave mattress placed, per [Hospice provider] request. Skilled OT evaluation only since resident is on hospice. Window side bed rail approved to prevent resident from falling out of bed and safety.
Review of witness statement from a Licensed Practical Nurse (Employee E5), dated February 12, 2024, revealed when Employee E5 took Resident R1 to the bathroom for incontinence care, Employee E5 was not able to lift Resident R1 out of the scoot chair. Employee E5 found a pair of fleece type pajama pants was tied around the midsection of Resident R1, in a knot, behind the scoot chair. Employee E5 immediately called Employee E3 to witness findings. Employee E5 then called the RN Supervisor, Employee E4 to inform of findings. Employee E5 noticed a reddening area on Resident R1's abdomen, therefore, Employee E5 removed the pajama pants prior to Supervisor Employee E4's arrival on the unit.
Review of an undated witness statement from Licensed Practical Nurse (Employee E6), revealed that Employee E6 observed Resident R1 sitting in a scoot chair, Resident R1 was restless, Employee E6 administered PRN (as needed) Morphine around 8:00 p.m., to help with restlessness. Employee E6 denied seeing anything tied around Resident R1 at the time of care.
Review of Resident R1's records failed to reveal a care plan for restlessness, scoot chair use, restraints, or bed rails.
Interview with the Nursing Home Administrator and Director of Nursing on February 14, 2024, at 12:10 p.m. confirmed that no pre-restraining assessment was performed, and no restraint documentation, including a care plan, was available for Resident R1 since it was the administrations opinion that Resident R1 was not restrained, rather, staff were taking it upon themselves to prevent Resident R1 from falling by tying him/her to a scoot chair for safety. It was confirmed that Resident R1 was approved for window side bedrail and scoot chair yet review of resident records failed to reveal a care plan for either. It was confirmed that Resident R1 showed signs of terminal restlessness yet review of resident records failed to reveal a care plan with interventions for this condition.
28 Pa Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 03/08/2024
Resident R1 expired 1/13/24 on hospice services. All residents will have a comprehensive care plan that will be consistently updated with changes to the resident's condition and care needs. All residents receiving hospice services will have a hospice care plan in place for nursing to reference. Hospice care plans must remain updated with changes to resident interventions as needed to maintain the goals of hospice care.
To identify other residents having the potential to be affected by the same deficient practice, 30 high and medium risk resident care plans will be audited by nursing and resident assessment to ensure that residents have a comprehensive care plan reflecting current care needs and the interventions in place to meet the current needs. Care plans failing to meet these criteria will be updated immediately. These audits will be done weekly for 4 weeks then monthly for 3 months. Audit results will be reported to the QAPI committee and discussed at the quarterly QAPI meeting.
System changes in the facility will include daily reporting of all residents receiving hospice services and/or having changes in condition. Necessary care plan updates will be communicated to resident assessment to validate documentation of same.
All licensed staff will be re-educated on the IDT communication requirements necessary to develop a comprehensive care plan, how to complete a care plan and how to immediately update a care plan when a change occurs for the resident. Facility expectations of hospice communication and documentation management will be discussed with and implemented by contracted hospice leadership.
Preparation and submission of this Plan of Correction is required by State and Federal law. This Plan of Correction does not constitute an admission for purposes of general liability, professional malpractice, or any other court proceeding.
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