§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 a review of clinical records and staff interview, it was determined that the facility failed to develop person-centered comprehensive care plans to meet the current needs and problems of three out of 18 residents sampled (Residents 33, 64, and 22).
Findings include:
A review of the clinical record revealed that Resident 33 was admitted to the facility on December 7, 2022, with diagnoses that included hypertensive heart disease.
A review of Resident 33's laboratory results report dated January 2, 2024, revealed that the resident had tested positive for RSV (Respiratory Syncytial Virus). However, the resident's care plan, in effect at the time of the survey ending January 11, 2024, failed to reflect the resident's diagnosis of RSV and interventions to treat and manage the resident's symptoms.
A review of the clinical record revealed that Resident 64 was admitted to the facility on February 24, 2023, with diagnoses that included Alzheimer's disease with late onset and epileptic seizures.
A review of Resident 64's laboratory results report dated January 3, 2024, revealed that the resident tested positive for RSV. However, the resident's care plan, in effect at the time of the survey ending January 11, 2024, failed to reflect the resident's diagnosis of RSV and interventions to treat and manage the resident's symptoms.
Interview with the Nursing Home Administrator and Director of Nursing on January 11, 2024, at approximately 1:40 PM confirmed the facility failed to ensure that comprehensive care plans were developed for Residents 33 and 64.
A review of the clinical record revealed that Resident 22 was admitted to the facility on October 11, 2023, with diagnoses that included depression.
A review of a nurse's note Employee 5, LPN, entered into the clinical record dated December 3, 2023, at 10:19 PM indicated that the resident's resident representative approached the desk and stated that he was upset because the resident stated that he wanted to kill himself. Employee 5 (LPN) sat with the resident and the resident stated, "I'm just down in the dumps." One to one supervision and reassurance were offered to resident. Resident stated,"I would never hurt myself." Every 15 minute checks were initiated. The registered nurse supervisor was made aware of the situation.
A nurses note dated December 4, 2023, at 1:43 PM indicated that Resident 22 stated that he feels safe and that he does not want to harm himself or others. Nursing noted that the resident was resident resting comfortably in bed watching television.
Review of a Psychiatric New Evaluation dated December 11, 2023, indicated that Resident 22 was evaluated for anxiety and adjustment issues. When the resident was asked about past suicidal statements the resident stated "that was just to get attention." The resident was diagnosed with adjustment disorder with anxiety, depressed mood and mild neurocognitive disorder. The plan was to continue current medications, supportive care, reorient, redirect, psychiatric team to monitor mood and behavior, encourage resident to participate in activities on the unit, and follow-up in four weeks.
Resident 22's clinical record revealed nurses notes dated December 24, 2023, December 28, 2023, December 30, 2023, January 1, 2024, January 4, 2024, January 6, 2024, and January 7, 2024, which indicated that the resident had displayed inappropriate verbal and physical sexual behaviors towards staff.
A review of Resident 22's current comprehensive care plan initially dated October 11, 2023, revealed that the resident's diagnosis of depression, suicidal statements, newly diagnosed adjustment disorder with anxiety and depressed mood, mild neurocognitive disorder, and inappropriate sexual behaviors were not identified along with corresponding treatment and management interventions.
Interview with the Nursing Home Administrator and Director of Nursing on January 11, 2024, at approximately 1:50 PM confirmed the facility failed to include the above residents' current problems and needs on their comprehensive plans of care.
28 Pa Code 211.12 (d)(3)(5) Nursing Services.
| | Plan of Correction - To be completed: 02/12/2024
The community will develop and update a person center care plan, said care plan will be updated when the need arises and per regulations. Residents 33, 22, and 64 will have a new Care plan review completed by the IDT. The interdisciplinary team will be educated on the care plan review process as A Care plan review is completed on all residents at least quarterly. The MDS coordinator will open and coordinate completion of the Care plan review within 14 days of each assessment reference date. The community completed a designation of duties to assign acute issues that need to be addressed in the care plan to specific members of the interdisciplinary team. The DON will audit assigned areas 1x a week x 4 weeks, then Monthly until 100% compliance is achieved . DON or designee will audit Care plan reviews for timing and accuracy 1 time a week for 4 weeks then monthly until 100% compliance is achieved. The team will complete a care plan audit based on diagnosis for the following Care plan items Cognition, Cardiac, Seizure, Anxiety, Depression. Results from Audits will be brought forward to QAPI.
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