§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 and clinical records and staff interview, it was determined that the facility failed to review and/or revise resident care plans for three of 13 residents reviewed (Resident R8, R11, and R13).
Findings include:
Review of facility policy dated 12/19/23, entitled "Comprehensive Care Plans" indicated "A Comprehensive Care Plan must be developed within seven days after completion of the comprehensive assessment" and "Periodically reviewed and revised by a team of qualified persons after each assessment".
Resident R8's clinical record revealed an initial admission date of 7/19/24, and a readmission date of 7/24/24, with diagnoses that included diabetes, high blood pressure, and chronic kidney disease (kidneys do not function properly in removal of excessive fluids and waste that is then removed through your urine).
Review of Resident R8's comprehensive care plan on 8/19/24, revealed that of the 16 care plans present, 16 had an outstanding target date of 8/13/24. The care plans included the problem categories of: self-care, discharge plan, skin integrity, falls, activities, nutrition, code status, anti-anxiety medications, cardiovascular, ostomy, diabetes, antibiotic use, pain, constipation, catheter, and hypothyroid.
Resident R11's clinical record revealed an admission date of 7/23/24, with diagnoses that included left hip fracture, diabetes, and high blood pressure.
Review of Resident R11's comprehensive care plan on 8/19/24, revealed that of the 14 care plans present, 14 had an outstanding target date of 8/12/24. The care plans included the problem categories of: self-care, falls, bleeding due to anticoagulant use, cardiovascular, skin integrity, discharge plan, constipation, GERD, nutrition, activities, pain, code status, bladder incontinence, and antibiotic use.
Resident R14's clinical record revealed an admission date of 6/30/23, with diagnoses that included dementia (loss of cognitive functioning affecting a persons memory and behaviors) chronic obstructive pulmonary disease (COPD - a lung disease that affects airflow from the lungs resulting in difficulty breathing, cough, mucus production and wheezing), and gastroesophageal reflux disease (GERD - a chronic disease when the stomach acids frequently flow back into the esophagus causing irritation and discomfort).
Review of Resident R14's comprehensive care plan on 8/19/24, revealed that of the 17 care plans present, 17 had an outstanding target date of 8/10/24. The care plans included the problem categories of: falls, skin integrity, code status, self-care, discharge plan, pain, nutrition, activities, psychotropic medication use, constipation, cognition, bladder incontinence, COPD, anti-anxiety medication, anti-depressant medication, behaviors, and GERD.
During a telephone interview on 8/21/24, at approximately 12:00 p.m. the Nursing Home Administrator confirmed that Residents R8, R11, and R14's care plans were not reviewed and/or revised within the required timeframe.
28 Pa. Code 211.12(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 10/04/2024
The three identified resident care plans were immediately updated to reflect current care plans.
A house wide audit of care plans will be completed by the Interdisciplinary team or designee to verify accuracy of the current care plan and ensure all target dates are compliant.
Licensed nursing staff will be educated by the Director of Nursing on 9/6/2024 on the importance of accuracy of completion by target dates in care plans.
The Interdisciplinary Team or designee will audit 5 resident care plans daily for accuracy of dates for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.
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