§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 reviews and staff interviews, it was determined that the facility failed to develop individualized care plans that included the care and services for an ileostomy (a hole/stoma in the abdominal wall which allows waste to leave the body) for one of 15 residents reviewed (Resident 4).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated December 7, 2023, revealed that the resident was cognitively impaired, required assistance from staff with daily care needs, and had an ileostomy.
Resident 4's care plan, dated February 20, 2024, revealed that the resident had an alteration in bowel elimination; however, the care plan did not contain resident-specific interventions related to the resident's ileostomy.
An interview with the Director of Nursing on March 12, 2024, at 4:17 p.m. confirmed that Resident 4's care plan did not include anything regarding the resident's ileostomy.
28 Pa. Code 201.24(e)(4) Admission Policy.
| | Plan of Correction - To be completed: 04/17/2024
Care Plan for resident 4 to reflect ileostomy. The Registered Nurse Assessment Coordinator (RNAC) will complete a house audit for all residents with an ileostomy and ensure an individualized care plan for the resident's care needs. Nursing Home Administrator (NHA)/designee will educate the RNAC and Licensed Practical Nurse Assessment Coordinator (LNAC) on the facility policy and procedures for updating care plans, ensuring that care plans have been devised for residents to meet their needs. The RNAC/Designee will complete an audit weekly for 2 weeks then monthly for 2 months to validate that care plans have been devised for residents to meet their individual care needs. The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review.
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