§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 upon review of clinical records, review of facility documentation, and staff interview it was determined the facility failed to follow a resident's care plan resulting in fall with subsequent actual harm of a hematoma requiring transportation to the Emergency Room for evaluation and treatment of a hematoma for one of three residents reviewed (Resident 52).
Findings include:
Review of Resident 52's care plan for continence at the time of the fall revealed "Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m."
Review of Resident 52's progress notes dated December 28, 2024, at 11:30 a.m. revealed "Firbank East [FE] nurse heard a loud "thump" from lounge area, when FE nurse walked over to see what the noise was, FE nurse discovered [Resident 52] on the floor, laying on right side in front of Broda chair, laying parallel to TV stand. Resident stated "I don't feel good. I feel dizzy. Resident assessment: oriented to self at baseline, lethargic, difficulty opening eyes and following commands, PERRL [pupils equal and reactive to light], large hematoma to right forehead measuring approximately 6 centimeters [cm] x 6 cm, c/o [complaining of] buttock pain, c/o dizziness and upset stomach. Education completed with FE staff regarding toileting care plan. Injuries: right forehead hematoma, skin slightly abrased but no bleeding or drainage."
Further review of Resident 52's progress notes revealed Resident 52's power of attorney was notified, and it was agreed to send Resident 52 to the Emergency Room to rule out a bleed in the head.
Review of Resident 52's progress notes dated December 28, 2024, at 9:58 p.m. revealed "spoke with ER [emergency room] nurse at [acute care facility]. Report received - EKG [electrocardiogram] stable; CT (computed tomography -medical imaging test that combines X-ray technology with computer processing to create detailed cross-sectional images of the body) scan of head and neck completed; both scans were negative. Resident cleared to return to facility."
Review of Resident 52's progress notes dated December 29, 2024, at 1:33 a.m. revealed "Resident returned from [Emergency Room of local hospital] at 00:10 a.m. to room 816. Resident awake and alert, at baseline with mentation; resident denies pain; bruising to right temple and right outer orbital. Resident had CT scans at [acute care facility] of head without contrast and of cervical spine. Head CT showed no acute intercranial abnormality, CT to spine showed no acute fracture. Resident was assessed. Resident had smear of feces to bilateral buttocks on return and was cleaned and brief put in place."
Review of Resident 52's care plan for continence at the time of the fall revealed "Toileting program: check and change upon awake, before bed, before and after meals, at midnight, 3 a.m. and 6 a.m."
Review of facility documentation revealed Resident 52 was seen earlier in the morning by an RN (Registered Nurse) at the facility at the dining room table. Resident 52 was "scooching" towards the edge of the Broda chair and was repositioned at that time.
Further review of facility documentation revealed Resident 52 was seen approximately 30 minutes prior to the fall by two staff members. At that time, Resident 52 was also attempting to move forward in the Broda chair. The two staff members repositioned Resident 52 in the Broda chair.
Review of facility investigative documentation revealed in section titled "Post Fall Investigation" revealed , "Last time toileted (approximately): 0900 (9:00 a.m)." Further review of same document revealed enquiry of Continent at time of fall: 'unknown -res (resident) transferred to ER, per FE nurse, resident did "feel wet."
Additional review of the facility investigative documentation revealed the toileting care plan was not followed and the root cause of the fall was failure to follow Resident 52's toileting care plan.
Interview with Licensed Employee E3 on January 9, 2025, at 11:37 a.m. revealed that Resident 52's care plan was not followed and the facility re-educated facility staff on following the care plan.
The facility failed to follow Resident 52's toileting care plan, resulting in a fall which required transfer to Emergency Room for evaluation, testing, and possible treatment due to a large hematoma to Resident 52's face causing actual harm to Resident 52.
28 Pa. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 03/07/2025
In accordance with Facility Policy-Comprehensive Person-Centered Care Plan (#11.01), the Interdisciplinary Team will meet each resident's goals, based on a comprehensive assessment of the resident's physical, psychological, social and spiritual needs. In addition, in accordance with Facility Policy – Minimum Data Set (MDS) Completion (#11.02), residents residing in skilled nursing will be assessed by the Interdisciplinary Team upon admission, annually, quarterly and with significant change in condition.
A review of Resident #52 indicated the facility completed assessments for reference periods 5-14-24 to 5-20-24 (Comprehensive Admission Assessment); 8-14-24 to 8-20-24 (Quarterly Assessment) and 11-13-24 to 11-29-24 (Quarterly Assessment).
A comprehensive review of Resident #52 Care Plans was completed January 23, 2025 by the Interdisciplinary Team and found to be current. All resident care plans are reviewed annually, quarterly and with significant change in condition.
In accordance with the Facility Policy 5.13 – Resident Info SNAP Sheet, the Facility will conduct an audit using the Care Plan Audit Form of all current resident Care Plans, covering Activities of Daily Living, Continence and Falls Prevention Care Plans to ensure Care Plans are current no later than March 7, 2025. Findings will be reported at the next quarterly Quality Assurance Committee meeting.
Utilizing a Care Plan Monitoring Tool, beginning February 17th, 2025, a Facility staff member/designee shall monitor 10% of current residents weekly for the first four weeks to ensure care plans of current residents are being followed. Thereafter, monitoring of 10% of current residents will occur on a monthly basis up to 90 days. Findings will be reported at the next quarterly Quality Assurance Committee meeting.
All staff will be educated on the definition, importance, and process for the comprehensive plan of care of residents no later than 2/21/2025.
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