|§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.
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that care plan interventions were implemented for one of five sampled residents. (Resident 45)
Clinical record review revealed that Resident 45 had diagnosis that included a gastrointestinal bleed, difficulty swallowing, glaucoma (visual difficulty) and dementia. Resident 45's care plan was most recently reviewed on December 20, 2019, and discussed with the resident's Guardian on January 2, 2020. The care plan identified the resident at risk for falls, at risk for complications in gastrointestinal status and at nutritional risk.
On August 13, 2019, the resident had a fall. The care plan initiated on August 15, 2019, indicated that staff was apply a chair alarm and check the function of the alarm every shift. On January 23, 2020, at 10:00 a.m., 12:30 p.m., and 1:15 p.m., Resident 45 was observed seated in the wheelchair without the chair alarm activated. In an interview at 1:15 p.m. NA1 confirmed that the box that activated the chair sensor pad was not present. NA1 also confirmed that she had provided care to the resident in the morning and had assisted the resident to her chair that morning without checking that the chair alarm was activated. After further observations the box could not be found in the resident's room. The Director of Nursing had to obtain the activation alarm box from central supply.
On December 10, 2019, Resident 45 was admitted to the hospital with a gastrointestinal bleed. The care plan initiated on December 14, 2019, indicated that staff was to obtain and monitor laboratory work and diagnostic studies as ordered by the physician. On January 9, 2020, the physician ordered that staff obtain a bowel movement sample for occult blood. This test indicated the presence or absence of blood in the stool. Review of the resident's bowel documentation revealed that the resident had bowel movements almost daily. There was no evidence to support that staff had obtained the stool sample and tested it for occult blood. In an interview on January 23, 2020, at 3:12 p.m., the Director of Nursing confirmed that staff had not tested the resident's bowel movement for blood. The Director of Nursing further confirmed that staff could complete the test in the nursing facility.
On January 2, 2020, staff initiated a new care plan that identified the resident with a history of weight loss. There was another ongoing care plan since January 30, 2019, that identified the resident with unplanned weight loss. Both care plans indicated that staff was to weigh the resident at the same time of day and record the results. 0n December 13, 2019, the physician ordered that staff weigh the resident three times a week. Review of the resident's weight records revealed that there was no weight obtained on ten of the 17 scheduled days since the December 13, 2019, physician's order. Additionally, an intervention dated January 6, 2020, noted that staff was to provide a peanut butter sandwich at bedtime and a calorie count was to obtained to determine if the resident was meeting nutritional needs. There was no documentation to support that a calorie count was completed. Review of the snack documentation revealed that the resident did not receive the sandwich snack on January 16 and 21, 2020.
CFR 483.21(b)(1) Comprehensive Care Plans.
Previously cited July 18, 2019.
28 Pa. Code 211.12 (d)(1)(5) Nursing services.
Previously cited July 18, 2019.
28 Pa. Code 211.5 (f) Clinical records.
| ||Plan of Correction - To be completed: 03/04/2020|
1.Resident 45 chair alarm box was placed on wheelchair.
Resident 45 Care Plan was updated to reflect non-compliance with chair alarm box.
Occult blood stool sample was discontinued by Physician.
Weight order was changed from three times a week to weekly by Physician.
Resident 45 calorie count cannot be corrected. The dietician assessed nutritional status and resident is stable.
The snack documentation cannot be corrected.
2. Care plans and documentation of chair alarm box, stool samples, weights,Calorie count and snack documentation were audited for completion.
3. RN's and LPN's will be in-serviced on protocol for orders for weights, chair alarms, calorie counts and stool samples. CNAs will be in serviced on snack documentation
4. Audits will be completed by DON/Designee for weights, chair alarms, stool samples, calorie count and snacks weekly x 4 weeks, and then monthly x 2 months. Audits will be reviewed at QAPI meeting.