§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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 25 residents reviewed (Residents 42, 55, and 73). Findings include:
Review of Resident 42's clinical record revealed diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]).
Review of Resident 42's progress notes from January 22, 2024, at 11:09 AM, revealed a progress note written by Employee 3 (Physician), that revealed Resident 42 had dementia and the plan of care was to, "continue with supportive care".
Review of Resident 42's MDS (Minimum Data Set evaluation), dated December 29, 2023, revealed in section I4800 that Resident 42 has an active diagnosis of Non-Alzheimer's dementia, meaning that the condition required and received treatment within the previous seven days. Review of Resident 42's care plan on February 5, 2024, failed to reveal any care planning for the Resident's dementia care. During a staff interview with the Director of Nursing (DON) February 8, 2024, at 9:45 AM, revealed that a care plan was developed and added to Resident 42's plan of care. She also revealed that the care plan should have been developed previously. Review of Resident 55's clinic record on February 6, 2024, at 1:05 PM, revealed diagnoses that included diabetes mellitus type 2 (DM II - body's inability to make/use insulin causing high blood sugar levels) and atrial fibrillation (fast irregular beats in the upper chambers of the heart).
Review of Resident 55's physician orders revealed the following orders: morphine sulfate (opioid pain medication) oral tablet 15 milligrams, give one tablet by mouth every 12 hours for pain; insulin glargine (long-acting insulin for controlling blood sugar) subcutaneous solution, inject 16 units subcutaneously two times a day for DM; insulin lispro (short-acting insulin for controlling blood sugar), inject eight units subcutaneously one time a day for DM II and inject six units subcutaneously two times a day for DM II; furosemide (diuretic to reduce extra fluid in the body) oral tablet 20 milligrams, give one tablet by mouth two times a day for diuretic; duloxetine HCl (increases the amount of mood-enhancing chemicals in the brain) oral capsule delayed release particles 30 milligrams, give one capsule by mouth one time a day for depression; and apixaban (used to thin blood) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots.
Review of Resident 55's comprehensive care plan revealed no care plan for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication.
During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 55 would have a care plan developed for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication.
Review of Resident 73's clinic record on February 6, 2024, at 12:37 PM, revealed diagnoses that included depressive episodes (feeling sad, irritable, empty) and venous thrombosis (condition that occurs when a blood clot forms in a vein).
Review of Resident 73's physician orders revealed orders for the following: escitalopram oxalate (antidepressant) oral tablet 20 milligrams, give one tablet by mouth one time a day for depression; bupropion HCl (antidepressant) oral tablet 75 milligrams, give one tablet by mouth one time a day for depression; and apixaban (anticoagulant) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots.
Review of Resident 73's comprehensive care plan revealed no care plan for the use of antidepressant and anticoagulant medications.
During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 73 would have a care plan developed for the use of antidepressant medication and anticoagulant medication.
28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 03/12/2024
1. Resident 42's care plan was updated to reflect Dementia Care. Resident 55's care plan was updated to reflect opioid pain medication, insulin, antidepressant medication, and anticoagulant medication. Resident 73's care plan was updated to reflect antidepressant and anticoagulant medications 2. A comprehensive review of current residents will be completed by the RNAC/designee to identify Care Area Assessments triggering for Dementia, opioid pain medications, Insulin, Antidepressant medications, and anticoagulant medications over the last 90 days will be reviewed to ensure development of plan of care. 3. The facility will take the further steps to ensure the problem does not reoccur by inservicing the Interdisciplinary care plan team on the development and implementation care plans and Focus on Ftag F656 by the DON/designee. The RNAC will bring to the eagle room the Care Area Assessment Summary Report for those residents that are due for care plan updates. The Interdisciplinary Care Plan (ICP) team will be responsible for updating the care plan to reflect the resident's current needs. 4. Compliance will be monitored by the Director of Nursing/designee through five audits of resident care plans weekly x2 weeks and monthly x2 to validate that Dementia Care, Opioid pain medications, antidepressant, and anticoagulant medications are appropriately care planned. Audit results will be reported to the QAA committee and the QAA committee will determine the need for further audits.
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