|§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 observation, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that comprehensive person-centered care plans were developed to reflect the individual needs, for four of 35 resident records reviewed (Residents R67, R37, R85 and R59)
Review of the clinical record for Resident R67 revealed that the resident was admitted to the facility on July 14, 2016, with a diagnoses to include Epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). Continued review of Resident R 67's clinical record revealed no comprehensive care plan had been been developed related to the resident having a seizure disorder.
Interview on December 13, 2019, at 12:35 p.m., with the DON (Director of Nursing), where she confirmed that Resident R67'S diagnosis included epilepsy and further confirmed that no comprehensive care plan had been been developed related to the resident having a seizure disorder.
Review of Resident R37's clinical record revealed that the resident was admitted to the facility on November 27, 2019. Diagnoses included but not limited to, Chronic Kidney Disease Stage 4 (A person with stage 4 chronic kidney disease has advanced kidney damage and will need dialysis or a kidney transplant in the near future) and an Acquired Arteriovenous Fistula (AV fistula) (An AV fistula is a connection, made by a vascular surgeon, of an artery to a vein, without this kind of access, regular hemodialysis sessions would not be possible).
Review of physician order for Resident R37 dated November 27, 2019 indicated an order to keep catheter clamp at bedside at all time. It also ordered to monitor dialysis site every shift. Physician order also indicated dialysis on a Monday- Wednesday-Friday schedule.
Review of the care plan for Resident R37 on December 16, approximately at 10:05 a.m., revealed that Chronic Kidney Disease Stage 4, and Acquired Arteriovenous Fistula were not identified as the diagnosed problems in the comprehensive care plan, and there were no interventions and outcomes(Goals) care planned for these problems.
On December 16, approximately at 11:24 a.m., the Assistant Director of Nursing confirmed that the findings regarding the comprehensive care plan for R37 were accurate.
Review of the nursing notes for Resident R85 indicated that the resident was admitted into the facility on October 2, 2019 with diagnoses that included, but not limited to heart failure (heart failure-a progressive heart disease that affects pumping action of the heart muscles); chronic obstructive pulmonary disease (COPD-a disease that causes decreases the ability of lungs to perform), and visual impairment.
Review of the resident's interdisciplinary notes from the facility psychiatrist revealed that the resident was being seen by the psychiatrist and a psychologist for behavioral services related to depression, anxiety, adjustment issues related to her visual impairments, and not being able to be as independent as she was prior to the onset of her blindness.
Review of Resident R85's interdisciplinary notes from December 3, 2018 through the November 25, 2019, revealed that Resident R85 was evaluated and treated by the psychiatrist a total of nine times during the above referenced time period, and evaluated and treated by a psychologist three times during this time period, for behavioral health services related to depression, anxiety and adjustment issues related to Resident R85's loss of independence, as a result of her visual impairment.
Review of Resident R85's person-centered plan of care did not include any objectives, interventions or time frames regarding Resident R85's mental and psychosocial needs to ensure that Resident R85 attained or maintained her highest practical mental and social well-being.
During a discussion with the Director of Social Services (Employee E3) on December 16, 2019 at approximately 10:05 a.m. Resident R85's person-centered plan of care was discussed. During this time, the Director of Social Services confirmed that Resident R85 is being see by the psychiatrist and psychologist for depression. When Employee E3 reviewed Resident R85's person-centered plan of care during the above-referenced discussion, Employee E3 reported that the person-center plan of care for the resident did not include a care plan to address the resident's behavioral health needs.
Review of Resident R59's clinical record revealed the resident was admitted to the facility on August 20, 2019, with a diagnosis including, but not limited to, dementia (A group of thinking and social symptoms that interferes with daily functioning).
Review of Resident R59's clinical record revealed a psychiatry note dated October 7, 2019, which revealed " ... Nursing-the pt has been urinating all over the unit. He cannot be redirected. When I see the pt today he is alert,pleasant,verbal. He does not recall urinating in inappropriate places. Gives illogical responses ... "
Further review of the resident's clinical record revealed no care plan was developed with measurable goals and interventions to address the care and treatment for dementia.
The facility failed to ensure that a comprehensive person-centered care plan was developed for four residents.
28 Pa. Code 211.5 (f) Clinical records
Previously cited 12/28/18
28 Pa. Code 211.11 (c) Resident care plan
Previously cited 11/27/18
28 Pa. Code 211.12(d) (1) (5) Nursing services
Previously cited 9/13/19, 5/15/19, 1/28/19 and 12/28/18
28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 5/15/19, 1/28/19 and 12/28/18
| ||Plan of Correction - To be completed: 01/27/2020|
1.R67, R37, R85 and R59s Care Plans were reviewed and revised to reflect a comprehensive patient centered care plan to meet the resident's individualized needs.
2.Resident care plan goals and interventions related to seizure disorders, chronic kidney disease, behavioral health needs, and dementia will be reviewed on admission, quarterly and with any significant change to assure that a comprehensive person-centered plan of care was initiated.
3.The interdisciplinary team will be educated by the Staff Development/designee on the importance of developing/revising and implementing a comprehensive person centered care plan to meet the individualized needs of the residents.
4.Random audits will be conducted by DON/designee to ensure that comprehensive care plans have been developed related to seizure disorders, chronic kidney disease, behavioral health needs, and dementia. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.