§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.
|
Observations:
Based on clinical record review, and staff interview, it was determined that the facility failed to implement care planned interventions for two of three sampled residents. (Residents 1, 3)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included diabetes and peripheral vascular disease (a circulation disorder). On January 29, 2024, the resident received diabetic foot support sneakers. The foot specialist recommended frequent foot examinations to identify pressure areas and for foot health. A review of the care plan revealed that staff were to check the resident's feet for signs of pressure or indentation and to relieve pressure on the resident's feet every two hours. Review of the clinical record revealed there was a lack of documentation to support that staff checked the resident's feet as per the care plan. In addition, the care plan indicated that the resident had the potential for impaired skin integrity, and staff were to check the resident's skin every shift for the development of open areas, scratches, cuts, and/or bruises and report changes to the nurse. There was a lack of documentation to support that the resident's skin was checked 14 of 87 times in February 2024, and three of nine times in March 2024.
Clinical record review revealed that Resident 3 had diagnoses that included dementia, cerebrovascular disease, and congestive heart failure. A review of the care plan revealed that the resident had the potential for impaired skin integrity, and staff were to check the resident's skin every shift for the development of open areas, scratches, cuts, and/or bruises and report changes to the nurse. There was a lack of documentation to support that the resident's skin was checked 16 of 87 times in February 2024, and four of nine times in March 2024.
During an interview on March 7, 2024, at 3:05 p.m., the Administrator stated that there was no evidence to support that the identified care plan interventions were implemented.
CFR. 483.21(b)(1) Comprehensive Care Plans
Previously cited 9/7/23.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 04/16/2024
STEP 1
FACILITY CANNOT RETROACTIVELY CORRECT
STEP 2
NHA DESIGNEE WILL CONDUCT AUDIT OF ALL RESIDENTS TO ENSURE CARE PLAN INTERVENTIONS ARE IN PLACE AS IT RELATES TO SKIN INTEGRITY AND ENSURE APPROPRIATE TREATMENTS ARE BEING COMPLETED PER THE CARE PLAN INTERVENTIONS TO REDUCE RISK OF FURTHER SKIN BREAKDOWN AND ENSURE COMPLIANCE WITH REGULATION.
STEP 3
NHA/ DESIGNEE WILL CONDUCT EDUCATION OF DON AND ALL NURSING STAFF TO ENSURE COMPLIANCE OF ADHERING TO CARE PLAN INTERVENTIONS AS IT RELATES TO SKIN INTEGRITY AND INSPECTION. NHA / DESIGNEE WILL CONDUCT WEEKLY AUDIT TO ENSURE COMPLIANCE AND ONGOING SYSTEMIC CHANGE
STEP 4.
NHA/ DESIGNEE WILL CONDUCT 3 AUDITS A WEEK X 4 WEEKS AND ONCE A MONTH X 2 MONTHS TO ENSURE APPROPRIATE CARE PLAN INTERVENTIONS ARE IN PLACE AND BEING ADHERED TO REDUCE RISK OF FURTHER SKIN BREAKDOWN AND ESNURE ONGOING COMPLIANCE WITH REGULATION. RESULTS WILL BE REVIEWED AT QAPI.
|
|
