§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 clinical records and staff interview, it was determined that the facility failed to revise a care plan for two of six residents (Resident R1, R2) to accurately reflect the current status of the resident.
Findings include:
Review of clinical record indicated Resident R2 was admitted 8/1/24, with diagnoses which included adult failure to thrive, Parkinson's disease without dyskinesia and neurocognitive disorder. A review of Resident R2's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/4/24, indicated diagnoses remained current.
Review of Resident R2's physician orders dated 12/5/24 indicated Safety Devices:Wanderguard on at all times: Check placement & skin integrity each shift. Change every 84 days was discontinued on 11/4/24.
Review of Resident R2's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 8/22/24, indicated elopement risk. Care Plan interventions included wandering device Device # A3423-3494.
Review of clinical record indicated Resident R1 was admitted 11/14/24, with diagnoses which included encephalopathy, cognitive communication mood disorder and dysphagia. A review of Resident R1's Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 11/21/24, indicated diagnoses remained current.
Review of Resident R1's physician orders dated 11/15/24 indicated Safety Devices: Wanderguard on at all times: Check placement & skin integrity each shift. Change every 90 days.
Review of Resident R1's Resident Care Plan Summary Report (report nurse aides used to know what kind of care to provide) dated 11/26/24, indicated elopement risk. Care Plan interventions was not updated to include wanderguard or updated for elopement incident.
During an interview on 12/27/24, at 1:30 p.m. Director of Nursing confirmed the facility failed to revise care plan for Resident R1 and R2 as required.
28 Pa. Code: 211.11(d) Resident Care Plan
| | Plan of Correction - To be completed: 01/15/2025
F 657 - Care Plans for Resident 1 and Resident 2 have been revised to include / exclude the door security system (Wanderguard), respectively. A baseline audit was conducted for residents with orders for safety devices and care plan revisions were made as indicated to include / exclude safety devices.
All licensed nurses will be educated on Care Plan creation, resolution, and revision by the Director of Nursing, or designee.
The Director of Nursing, or designee, will audit resident care plans, with orders for safety devices, five days a week for one week, weekly for three weeks, then monthly for two months.
Adverse outcomes will be reported to the QAPI committee at least quarterly.
The facility Director of Nursing shall ensure compliance.
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