§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 facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 35 residents reviewed (Resident R128).
Findings include:
Review of Resident R128's clinical record revealed that the resident was admitted to the facility on September 14, 2022 with the diagnoses of Colostomy Status (an operation that creates an opening for the large intestine, through the abdomen, to treat disease or to relieve an obstruction or to prevent the remaining bowel from contamination by fecal matter), and Dysphagia (difficulty swallowing) .
Review of physician order dated March 31, 2023, for Residnet R128, indicated an order stating, "Resident has a colostomy on the Right Upper Quadrant".
On February 27, 2024, at 12:23 p.m. Resident R128 was observed having his colostomy bag attached to his colostomy site.
Review of the care plan for Resident R128, on February 27, 2024, at 2:12 p.m., revealed that there were no focus, interventions, and outcomes (goals) care- planned for Colostomy care.
On February 27, 2024, at 2:12 p.m., interview with Employee E9, a Licensed Nurse, confirmed the above findings.
28 Pa Code 211.10 (c)(d) Resident care policies
28 Pa Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 04/17/2024
This plan of correction is submitted to comply with Federal Regulations. This plan is not an admission of guilt, or wrong doing, nor does it- reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1.] Facility has care planned the colostomy care for resident R 128 2.] All residents with an colostomy have the potential to be affected. Nursing will conduct an audit of all residents with an ostomy to ensure the ostomy is care planned. 3.] Professional Nurses will be educated on the need to care plan for colostomy care. 4.] DON or designee will conduct audits of all new admissions and new colostomy orders of existing residents to ensure ostomy care s care planned in the resident's medical record. Audits will be conducted weekly x 4 weeks then monthly x 2 months. Results of audits will be brought to QAPI to determine if there is need for further action.
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