Other·April 26, 2021

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. The facility failed to: 1. Follow policies and procedures for care planning, when the facility did not evaluate the effectiveness of the interventions for Resident 1's increasing aggressive behaviors; and, 2. Develop a care plan for victimization for Resident 3. This failure resulted in ineffective interventions which led to Resident 3 being attacked and suffering from facial pain and fear of violent people in her surroundings. 1. a) During an interview and concurrent record review on 09/04/19 at 3:30 p.m., the Director of Nursing (DON) stated Resident 1 was on every 15-minute safety checks the entire time Resident 1 was an inpatient in the facility (08/09/19 to 8/26/19). During an interview with the Assistant Director of Staff Development (ADSD), on 09/11/19, at 10:50 a.m., she stated care plans were opened at the time of admission, and some items may or may not apply to residents when they were admitted. The ADSD stated some of the items were not complete because Resident 1 did not make it in the first two weeks for Interdisciplinary Team (IDT) meeting. The ADSD described the process in order to gather information and make appropriate care plans for each resident. The ADSD stated the IDT meeting was for Resident 1 on 08/29/19, but he was transferred on 08/26/19, and officially discharged on 08/27/19. During an interview on 09/13/19 at 10:36 a.m., the Director of Nursing (DON) stated the facility did not conduct one-on-one monitoring in the post-acute facility, and if one-on-one monitoring were needed, the facility would place resident in an acute facility. During a review of Resident 1's clinical record, "Care Plan: Risk for Assault," initiated 08/09/19, indicated Resident 1's care plan noted his aggressive behavior history. Resident 1's goals included he would not assault anyone for 90 days, which was initiated on 08/20/19 (after Resident 1 and Resident 2's altercation). The care plan interventions indicated: - Staff to offer Resident 1 a safe and quiet environment, as needed, initiated on 08/12/19 - Staff will work with Resident 1 to develop a safety plan to prevent aggressive behaviors, initiated on 08/12/19 - Staff will work with resident to develop a safety plan to prevent aggressive behaviors, initiated on 08/12/19 - Staff to encourage resident to express feelings of anger/fear before aggressive behaviors occurs, initiated 08/20/19 - Staff to increase safety checks as indicated, initiated 08/27/19 The care plan did not indicate any changes on interventions addressing Resident 1's escalating aggressive behaviors. The care plan did not indicate an IDT meeting occurred to review and update the care plan for significant change in Resident 1's condition. The facility policy and procedure titled, "Care Planning - Interdisciplinary Team (IDT)," revised 12/16, indicated a comprehensive care plan for each resident is developed within seven days of completion of the required comprehensive resident assessment (MDS). It indicated, "Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change." It indicated IDT 'must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met.' Review of Resident 1's, "Assault Risk Assessment," on the following dates and times indicated: 1. On 08/20/19, Resident 1 was placed in category for moderate to high risk due to Resident 1 physically assaulting Resident 2. Resident 1's interventions included routine rounds, every 15-minute checks, licensed nurse assessment every shift, and for Licensed Nurse to initiate Care Plan on, "Potential for Assaultiveness." 2. On 08/26/19, it indicated Resident 1 was placed in a category for a high risk due to assaulting Resident 3. The care plan did not indicate changes or new interventions compared to the first Assault Risk Assessment on 08/20/19. During a review of the facility's policy and procedure titled, "Assault/Altercation - Resident to Resident," no date, indicated, "All residents with a history of assault will have a potential for assault care plan upon admission. Charge Nurse will begin or update the client's care plan and decide whether to proceed with the formulation of a potential for assault problem on the client's care plan based on clinical indicators, history, frequency, and severity." 1. b) During a concurrent interview and record review with the Assistant Director of Staff Development (ADSD), on 09/11/19, at 10:50 a.m., she stated Resident 1 was aware Testosterone (hormone therapy in transgender males - female to male) affected Resident 1's feelings and behaviors, and Resident 1 did not like that. The ADSD stated Resident 1 was concerned about getting very angry, very concerned about taking testosterone as it was making Resident 1 have behaviors of aggression and would lash out more so on the day of injection. The ADSD stated the treatment team was working with Resident 1 on this issue. The ADSD stated monitoring for increased aggression/agitation, after Testosterone injection, was part of the monitoring nurses did. Resident 1 was on hourly rounds and every 15-minute checks since he was admitted, to observe his behaviors. The ADSD verified there was no care plan intervention for Testosterone, for Resident 1's risk for medication side effects from hormone therapy treatment, secondary to gender transitioning related to testosterone treatment. During a review Resident 1's clinical record, "Medication Administration Record (MAR)," dated 08/23/19, indicated Resident 1 received Testosterone 200 mg injection. Testosterone side effects included emotional instability, loss of strength/energy, insomnia, depression, mood changes, behavioral changes, and thoughts of suicide (thinking about harming or killing oneself or planning or trying to do so). During a review of Resident 1's clinical record, his, "Care Plan," initiated on 08/09/19, indicated Resident 1 was at risk for medication side effects from hormone therapy treatment, secondary to gender transitioning related to testosterone treatment. The goal was for Resident 1 to report feelings of side effects from testosterone treatment to his nurse and or doctor, as needed, through next review date. The care plan did not indicate any interventions. 2) During a concurrent observation and interview on 09/04/19 at 2:30 p.m., Resident 3 stated she was sitting down in the interview room across from Resident 1, when Resident 1 attacked her. Resident 3 stated she went down on the floor during the attack. Resident 3 touched her face, left forehead, and cradled her left jaw, as she described that her jaw and temples hurt after the attack. Resident 3 stated, after the altercation with Resident 1, her body shook from pain and fear. Resident 3 stated feeling scared of other people who may be violent. Resident 3 stated she was now, 'watching her back' and expressed concern about possible future physical attacks. During a review of Resident 3's clinical record, "Care Plan," received on 09/04/19, the care plan did not indicate Resident 3's future safety to prevent behavioral regression after the physical abuse on 08/26/19. The care plan did not indicate how the facility could ensure Resident 3's safety and/or interventions to prevent further abuse. The facility policy and procedure titled, "Assault/Altercation - Resident to Resident," no date, indicated care planning interventions to consider, included: 1. Psychotropic medication evaluation and administration 2. Restriction from certain groups and public activities 3. Enhanced supervision including 1:1 supervision, as needed 4. Development of special positive based reinforcement programs to support assault free days 5. Room changes or hallway separation and eating in separate dining rooms During a review of the facility's policy and procedure, "Assault/Altercation - Resident to Resident," no date, indicated, "Clients who frequently fall victim to assault will need to be care planned for, Potential for Victimization. The Clinical Director/ or treating Psychiatrist will evaluate for continued stay in the program if indicated." Therefore, the facility failed to: 1. Follow policies and procedures for care planning, when the facility did not evaluate the effectiveness of the interventions for Resident 1's increasing aggressive behaviors; and, 2. Develop a care plan for victimization for Resident 3. The above violations had a direct or immediate relationship to the health, safety, or security of patients.