§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 facility policy review, clinical record review, and staff interviews, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to attain or maintain the highest practicable level of physical and mental well-being for one of 25 residents reviewed (Resident 49).
Findings include:
Review of facility policy, titled "Care Plans, Comprehensive Person-Centered", last revised September 2022, read, in part, "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs, is developed and implemented for each resident. The services provided or arranged by the facility, as per the comprehensive care plan, must be culturally-competent and trauma-informed ...Trauma-informed Care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization."
Review of Resident 49's clinical record revealed diagnoses that included Post-Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being) and Type 2 Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).
Review of Resident 49's clinical record revealed a Nurse Practitioner Note on February 22, 2023, that stated "Resident is a veteran of the Marine Corps and served in the Vietnam War. 2 Purple hearts and a bronze star."
Review of Resident 49's care plan revealed a focus area of "Richard has a mood problem related to history of PTSD and self-reported signs and symptoms of depression: history of feeling down/depressed, like a failure and has thoughts he would be better off dead (no plan to harm self)", initiated August 13, 2020, and last revised December 6, 2022. The care plan failed to reveal what caused his PTSD or triggers related to PTSD.
During an interview with Employee 4 (Director of Social Services) on March 12, 2024, at 2:33 PM, the surveyor inquired about Resident 49's diagnosis of PTSD. Employee 4 stated that Resident 49 has PTSD due to being a Vietnam Veteran, he has interventions in place for this, including that he follows with geri-psychiatric for talk therapy, and he goes out of the facility to the VFW (Veterans of Foreign Wars - war veterans service organization) to meet with other veterans and attend events such as flag burning ceremonies. Employee 4 further stated he used to sleep in a recliner, but stopped due sliding out of the recliner when he was having night terrors and flashbacks. She stated that those have gotten much better since he has been receiving geri-psychiatric services.
Further review of Resident 49's care plan on March 12, 2024, failed to reveal his interventions of going out to the VFW, or him experiencing night terrors and flashbacks.
Review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his focus area of his PTSD had been updated to state "history of PTSD (Vietnam Vet)" with interventions for "be sure to approach from the front, calling out name", initiated on March 13, 2024, and "does go out to VFW with friends on a regular basis", initiated on March 13, 2024.
Further review of Resident 49's care plan on March 13, 2024, at 1:00 PM, revealed his activities care plan was updated to state "He is a Vietnam Veteran with PTSD" with interventions for "Friends occasionally take him to the VFW with them", initiated on March 13, 2024, and "monitor/record/report any changes in feeling down or behavior or depression (PTSD- Vietnam Veteran)".
An interview with the Nursing Home Administrator on March 13, 2024 at 1:32 PM, revealed she would expect Resident 49's care plan to be comprehensive to include the source of his PTSD as well as his triggers and interventions.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
| | Plan of Correction - To be completed: 04/24/2024
1. R49s care plan was revised to include PTSD triggers and additional interventions. 2. Facility will complete audit of current residents with PTSD to ensure care plan includes triggers and all interventions for treatment of PTSD. 3. Education will be provided to the nursing and care plan team regarding ensuring appropriate and accurate interventions are in place, in addition to revising and updating care plans regularly as changes occur. 4. MDS coordinator/designee will audit care plans of 5 residents weekly x4 weeks, and 10 monthly x2 months to ensure care plans are updated and accurately reflect current conditions and interventions. Results will be reviewed at QAPI to ensure compliance and quality improvement.
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