§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 observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 23 residents reviewed (Residents 18 and 51).
Findings include:
Review of facility policy, titled "Care Planning-Interdisciplinary Team", revised September 2013, revealed, "Our facility's care planning/interdisciplinary team is responsible for the development of and individualized comprehensive care plan for each resident".
Review of Resident 18's clinical record revealed diagnoses that included muscle weakness (weakness of muscle movements) and fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue, and sleep disturbances).
Observation of Resident 18 on February 12, 2024, at 12:14 PM, revealed Resident 18 sitting in a recliner in her room wearing custom made orthotic shoes with built in AFO (an ankle foot orthosis controls the range of motion in your foot and ankle and helps to stabilize its position).
Review of Resident 18's care plan on February 12, 2024, failed to reveal any guidance regarding Resident 18's use of orthotic shoes with AFO.
Interview with the Director of Nursing (DON) on February 15, 2024, at 9:45 AM, revealed that Resident 18's care plan should have included the shoes with AFO brace.
Review of Resident 51's clinical record on February 12, 2024, at approximately 12:00 PM, revealed diagnoses that included cerebral infarction (stroke - sudden loss of blood to a part of the brain which results in damage and death of cells) and dysphagia (difficulty swallowing).
Observation of Resident 51 on February 12, 2024, at approximately 10:10 AM, revealed Resident 51 had a disposable tissue partially placed inside Resident 51's mouth.
During an interview on February 12, 2024, at approximately 10:20 AM, Employee 1 stated that Resident 51 frequently utilized a tissue placed in his mouth to soak up salivary secretion. During the interview, Employee 1 stated that staff do check Resident 51's mouth during the day to ensure pieces of tissue and/or food are not left in Resident 51's mouth.
Review of Resident 51's clinical record revealed Resident 51 was not care planned for placing a tissue in his mouth.
During an interview on February 14, 2024, at approximately 1:30 PM, DON confirmed that Resident 51 was known to place tissues in his mouth. DON stated that the family has provided cloth handkerchiefs, but Resident 51 still utilizes disposable tissues at times.
During an interview on February 15, 2024, at approximately 9:30 AM, DON provided an updated plan of care for Resident 51 which included the intervention of, "I have excessive [secretions]. Staff will encourage me to use handkerchiefs that my family provides but I like to at times use tissues. Staff will monitor my tissue use for concerns." During the staff interview, DON confirmed that the care plan should have reflected Resident 51's use of cloth handkerchief or tissues placed inside the mouth for salivary secretions.
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 04/08/2024
"Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law.
1.Resident 18's careplan was revised on 2/15/24 adding resident's orthotic shoes to her careplan. Resident 51's careplan was revised on 2/15/24 to reflect resident's preference to utilize tissues for secretions and will place the tissues in his mouth.
2. Resident careplans completed the last 14 days based on the MDS schedule were reviewed for accuracy in regards to adaptive equipment and resident preference/safety concerns and revisions completed as needed.
3. Policy on Care Plans, Comprehensive Person-Centered was reviewed and will be revised as needed by DON. Education was provided to the interdisciplinary team by the DON at meetings on 2/20, 2/21 and 2/22 for accuracy of the careplan.
4. Careplans will be audited by RNAC/DON for accuracy for adaptive equipment and resident preference/safety concerns. Audits of 5 careplans will be done bi-weekly x2 then monthly x3 in coordination with residents MDS schedule. QA will review audit findings.
Facility will initiate an Action plan which will record the audits and finding s and will be reviewed at the facilities Quality Assurance Meetings.
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