§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 staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to meet each resident's needs as related to a diagnosis of post traumatic stress disorder and as identified in the comprehensive assessment for two of 31 sampled residents. (Residents 8, 21)
Findings include:
Clinical record review revealed that Resident 8 had diagnoses that included post traumatic stress disorder (PTSD), depression, and Fourier's gangrene (tissue death). Review of a psychiatric consultation dated December 20, 2023, revealed Resident 8 was a combat veteran with PTSD. Review of the Resident Centered Care/All About Me Information Form dated February 3, 2024, revealed the resident had triggers from past trauma that included loud noises, fireworks, and cars backfiring. Resident 8's care plan did not include interventions to address the resident's PTSD diagnosis and related triggers to prevent re-traumatization.
Clinical record review revealed that Resident 21 was admitted to the facility on December 4, 2023, with diagnoses that included major depressive disorder and anxiety disorder. The Minimum Data Set assessment Care Area Assessment summary dated December 11, 2023, noted that the resident's psychotropic drug use was to be addressed in the care plan. There was no documented evidence that interventions to address Resident 21's psychotropic drug use were included in the care plan.
In an interview on February 23, 2024, at 9:34 a.m., the social worker (SW1) confirmed the identified areas were not addressed in Residents 8 or 21's care plans.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/12/2024
1) Resident 8 had a care plan placed for PTSD. Resident 21 has had a care plan placed for psychotropics.
2) To identify other residents that have the potential to be affected, the DON/designee completed an audit of residents who have a history of PTSD to ensure care plan is present. To prevent this from reoccurring, the DON/designee reviewed MDS completed in past week to ensure any CAA areas triggered have care plans to reflect.
3) To prevent this from reoccurring, the DON/designee educated social services to ensure care plans are in place for residents with a history of PTSD To prevent this from reoccurring, the regional reimbursement nurse/designee educated the MDS nurses on ensuring when a CAA is triggered, there is a corresponding care plan.
4) To monitor and maintain compliance, the DON/designee will review residents with history of PTSD weekly x4 then monthly x 2 to ensure a care plan is in place. To monitor and maintain ongoing compliance, the MDS nurse/designee will review MDS completed weekly x 4 then monthly x 2 to ensure a CAA that is triggered has a corresponding care plan.
5) The results of the audits will be forwarded to the facility QAPI committee for further recommendations and review.
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