|§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:|
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.
§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Based on review of clinical records, facility policy, and the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (provides instructions and guidelines for completing required Minimum Data Set [MDS - federally mandated periodic assessments of a resident care needs]), and staff and resident interviews, it was determined that the facility failed to ensure that residents and/or resident representatives were afforded the opportunity to participate in an admission interdisciplinary care plan meeting for two of 25 residents reviewed. (Residents R58 and R60)
The RAI User's Manual dated October 2019, indicated that resident involvement in care plan meetings is imperative to address dignity and self-determination and that residents should be asked if they desire family members, significant others and/or legally authorized persons to participate. The manual further directs that if the resident is unable to understand the process, or participate, family, significant others and/or legally authorized persons should be invited to attend if possible.
The facility policy entitled "Comprehensive Care Plan," dated 11/30/2020, revealed that resident care plans would be developed within seven days following the completion of the comprehensive assessment and would be prepared by an interdisciplinary team, and to the extent practicable, the resident and the resident's family or their representative.
Resident R60's Admission MDS dated 1/11/2021, revealed an admission date of 1/04/21, with diagnoses that included surgical aftercare following surgery on the nervous system (brain surgery following a traumatic head injury), a tracheostomy (an opening made into the windpipe to aid breathing), and a gastrostomy (an opening into the stomach through the abdominal wall usually for feeding/fluid introduction). The MDS revealed that Resident R60 had severe cognitive (mental) impairment; was totally dependent on two staff to move in bed, transfer, eat, dress and use the bathroom; and that oxygen and suctioning treatments were provided during the assessment period.
During an interview on 3/04/2021, at 1:00 p.m. the facility Corporate Registered Nurse indicated that when care plan meetings are conducted an Interdisciplinary Care Plan Meeting form is completed.
Resident R60's clinical record lacked an Interdisciplinary Care Plan Meeting form, or other documentation to reflect that an interdisciplinary care plan meeting was conducted or that Resident R60 and/or his/representative were invited to participate in an interdisciplinary care plan meeting following completion of the Admission Comprehensive MDS.
During an interview on 3/04/2021, at 1:15 p.m. the Director of Nursing (DON) confirmed that Resident R60's clinical record lacked evidence that Resident R60 and/or his/her representative were invited to participate in an interdisciplinary care plan meeting or that a care plan meeting was conducted following completion of the Admission Comprehensive MDS.
Resident R58's Admission MDS dated 10/13/2020, revealed an admission date of 10/06/2020, with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination with spastic [muscle spasms] paralysis typically caused by damage to the brain before or at birth); pressure ulcers of the sacrum (tailbone area) and buttock; and a neurogenic bladder (inability to urinate from a lack of nerve stimulation to the bladder). The MDS indicated that Resident R58 was interviewable and cognitively intact.
During an interview on 3/01/20/21, at 12:55 p.m. Resident R58 indicated that he/she was admitted after developing wounds of the buttocks/sacrum, had lived with friends prior to admission and remembered participating in "maybe one" care plan meeting since admission.
Resident R58's clinical record lacked an Interdisciplinary Care Plan Meeting form, or other documentation to reflect that an interdisciplinary care plan meeting was conducted or that Resident R58 and/or his/representative were invited to participate in an interdisciplinary care plan meeting following completion of the Admission Comprehensive MDS.
During an interview on 3/04/21, at 1:55 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that Resident R58's initial care plan meeting following admission was not conducted and that care plan meetings had not been conducted as required.
28 Pa. Code 211.11(e) Resident care plan
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| ||Plan of Correction - To be completed: 04/19/2021|
A Care Plan meeting was unable to be completed for R60 due to the resident discharging home.
A care plan meeting was completed with R 58 and their family on 3-17-21.
An audit of the all residents admitted in the last 3 months will be completed to determine if an initial care plan meeting took place and the resident and/or resident representative has been afforded the opportunity to attend the care plan meetings per the facility policy. Care plan meetings will be completed as needed.
All residents and/or representatives will be afforded the opportunity to participate in their interdisciplinary care plan meetings. The resident and/or resident's representative will be issued a letter indicating a care plan will occur prior to the meeting date. A follow up phone call will be made to the representative prior to the meeting for confirmation. A face to face contact will be made with the resident to confirm the meeting date and time.
Interdisciplinary team will be educated by the Corporate Registered Nurse on completing care plan meetings in accordance with the Long Term Care Resident Assessment Instrument and the facility policy by March 30, 2021.
Resident Services Coordinator will audit all the new admissions' initial care conferences to ensure compliance with the facility policy 5 times a week for two weeks, weekly times 2 weeks and then monthly for 2 months. The Director of Nursing will audit the Resident Services Coordinator.
Results of the audits will be reviewed at the Quality Assurance meeting monthly as needed.