§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 review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of five residents reviewed (Resident CL1).
Findings include:
Interview with Resident R1 conducted on March 13, 2024, at 10:00 a.m. revealed that "at nighttime, someone screams in the hallway and wakes me up every night."
Interview with Resident R2 on March 13, 2024, at 10:05 a.m. revealed that at approximately 3:00 a.m. a resident "yells and disturbs everyone's sleep." Resident R2 stated, "it is impossible to sleep through the screaming."
Interview with Resident R4 on March 13, 2024, at 10:20 a.m. revealed that Resident CL1 "screams every night, waking everyone up. It is unbearable."
Review of Resident CL1's clinical record revealed that Resident CL1 was admitted to the facility on January 17, 2024, with diagnoses including cardiogenic shock (heart cannot pump enough blood and oxygen to the brain and other vital organs) and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Further review revealed a progress note, dated February 16, 2024, "resident slept in bed quietly with signs of agitation and yelling this night."
Interview with Charge Nurse on the 7-3 p.m. shift, Employee E3, on March 13, 2024, at 12:33 p.m. revealed that, several times, the night charge nurse reported that Resident CL1 was being disruptive during the nighttime. Further interview confirmed that Resident CL1 did not have a care plan in place for his disruptive behaviors.
Interview with the Nurse Supervisor on the 7-3 p.m. shift, Employee E4, on March 13, 2024, at 12:35 p.m. revealed that the nighttime nurse, Employee E5, previously reported that Resident CL1 was "agitated at nighttime and screams." Further interview confirmed that Resident CL1 did not have a care plan in place for his disruptive behaviors.
Interview with the Nurse Supervisor on the 11-7 a.m. shift, Employee E6, on March 13, 2024, at 12:41 p.m. revealed that "some nights, [the Resident CL1] screams, this is how we know it was time to take him to the nursing station and give him a snack. Then he would calm down and go back to bed." Employee E6 confirmed that a care plan was not developed for Resident CL1's nighttime disruptive behaviors.
Review of Resident CL1's Care Plan date initiated, January 22, 2024, revealed that there were no focus, interventions, and outcomes (goals) care planned for Resident CL1's disruptive nighttime behaviors.
28 Pa Code 211.10 (c)(d) Resident care policies
| | Plan of Correction - To be completed: 04/03/2024
1. CL1 no longer resides in the facility.
2.Current residents checked to ensure behaviors are care planned with appropriate interventions.
3.Licensed staff will be in-serviced to ensure resident behaviors are care planned.
4.NHA or designee will audit residents weekly to ensure identified behaviors are care planned. Results of the audits will be reviewed with the QAA committee. The QAA Committee and continued audits will determined by the QAA committee.
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