§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 it was determined that the facility failed to develop and/or implement a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of three sampled residents. (Resident 1)
Findings include:
Clinical record review revealed that Resident 1 was admitted to the facility on April 18, 2025, with diagnoses that included atrial fibrillation (an irregular heart rhythm) and an infection in the skin. According to the Minimum Data Set assessment, dated April 18, 2025, the resident was dependent on staff for care, had multiple wounds, and had heart disease. On April 21, 2025, a nurse practioner noted that the resident has prior surgeries including the placement of an internal cardioverter/defibrillator (a device that administers a shock to correct certain abnormal rhythms). There was no documentation that the facility included interventions on the plan of care to monitor and care for this device.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 05/29/2025
1.Care plan updated to include interventions to monitor and care for the resident's internal cardioverter/defibrillator.
2.Facility will complete an audit of all residents in facility to determine the presence of internal devices. Residents affected will have care plans updated to address the monitoring and care of said devices.
3.Education will be provided to licensed nurses on addressing individual resident needs on their care plan as identified in the comprehensive assessment.
4.Audits will be completed by DON or designee 3x/week for 4 weeks, and then weekly x4 to ensure compliance. Results will be presented at QAPI.
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