|§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.
Based on a review of clinical records, observation, resident and staff interview it was determined that the facility failed to implement care plan interventions for one of five residents reviewed, (Resident 5).
Review of a facility policy titled, "Assistance with Meals," last reviewed November 2018, revealed a section for "Residents Requiring Full Assistance". Review of this section revealed "Nursing staff/ Feeding Assistants will remove meals from the from the food cart and deliver to each resident's room. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals; keeping interactions with other staff to a minimum while assisting, residents with meals".
A review of the clinical record revealed that Resident 5 was admitted to the facility on May 23, 2013. Current diagnoses include adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity) and encounter for palliative care (specialized medical and nursing care for people with life-limiting illnesses, focusing on providing relief from the symptoms, pain, physical stress, and mental stress associated with end of life).
Observation on June 17, 2019, at 12:42 PM revealed Resident 5 in bed in her room with the overbed table in position in front of her, with an uncovered meal sitting on it. There was no staff in the room at the time of observation. When asked why she wasn't eating Resident 5 replied, "waiting for someone to help me eat."
A review of Resident 5's current plan of care revealed a focus care area, "resident has potential nutritional problem related to elevated BMI (Body Mass Index), therapeutic diet, Edentulous (not having own teeth), not wearing dentures; depleted protein stores". Interventions included in this focus group included, "Resident requires assistance at meals", which was initiated on April 29, 2019 and still active at the time of observation. An additional intervention of, "Resident to be fed by staff", also initiated on April 29, 2019, was active at the time of observation.
At the observation of Resident 5 in her room alone, without assistance to eat, the Nursing Home Administrator, who was accompanying this surveyor, went to the nurse's station to obtain assistance for this resident. After 8 minutes of waiting, without staff coming to assist, the Director of Nursing entered the room and started assisting the resident to eat.
Interview with the Nursing Home Administrator on June 17, 2019, at approximately 5:40 PM revealed her expectation that the plan of care should be followed.
28 Pa Code 211.11(d) Resident care plan.
28 Pa Code 211.12(c)(d)(5)Nursing Services.
| ||Plan of Correction - To be completed: 07/28/2019|
Development and/or execution of this plan of correction does not constitute and admission or agreement by this provider of the truth in this statement of deficiency. This poc is prepared and or executed by provision of State and or Federal law.
1. Resident #5 was reassessed by the Speech Therapist to determine assistance needed for meals. The care plan was updated with any new findings.
2. A 100% audit was completed on all residents for level of assistance required for meals. All meal tickets, care plans and Kardex's were updated to reflect any changes.
3. All Unit Managers were re-educated on their role during meal service by the NHA to ensure residents requiring feeding assistance have it. Random audits have been completed weekly x four weeks to determine compliance with feeding assistance as identified through the most current audit. All unit staff have received a post-test to ensure staff are aware of what assistance each resident needs during meal service. Department Directors will randomly audit weekly x four weeks to ensure compliance. The Unit Managers/Nursing Administration to monitor.
4. Feeding assistance audits will be completed every 90 days or sooner as indicated by a decline and/or improvement for each resident by therapy and a direct care representative. Meal tickets will be updated and staff notified of any changes made before the audit schedule. The NHA/DON/designee will monitor for compliance and update monthly as needed at the QAPI meeting.