Other·January 13, 2023

F656 §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. 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 10/7/2019, the Department of Public Health (DPH) received a facility reported incident (FRI) reporting Resident A suffered an unwitnessed fall on 10/4/2019. On 10/12/2019, an unannounced visit was conducted at the facility to investigate the FRI. During the investigation it was determined Resident 1 was assessed as a high risk for falls. The care plan (CP) for Resident 1’sr high risk for falls was never developed. The facility failed to: 1. Ensure the licensed nurses developed a CP for the risk for falls for Resident A, who was assessed as being at high risk for falls. 2. Ensure the licensed nurses adhered to the facility’s policy and procedure (P/P) titled, “Care Plans, Comprehensive Person-Centered,” which stipulated a comprehensive, person-centered care plan is developed and implemented for each resident. As a result, Resident[GA1] A fell on 10/4/2019, required a transfer to a general acute care hospital (GACH) on the same day and was diagnosed with a fractured (broken bone) nose. During a review of Resident A's Admission Record (face sheet), the face sheet indicated Resident A, a 58 year-old female, was admitted to the facility on 3/6/2019, with diagnosis including cerebral infarction (a stroke resulting from the interruption of blood flow) affecting the right side of her body. During a review of Resident A's History and Physical (H/P), dated 3/8/2019, the H/P indicated Resident A had the capacity to understand and make decisions. During a review of Resident A's Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 3/13/2019, the MDS indicated Resident A was able to make independent decisions that were reasonable and consistent. According to the MDS Resident A set up help and supervision for bed mobility, transfers, walking in the corridors and room, locomotion on/off the unit and activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting), and required limited set up assistance to dress and bathe. The MDS indicated Resident A able to move from one location to another with supervision and use of a wheelchair for mobility[GA2]. During a review of the Admission Nursing Assessment (ANA), dated 3/6/2019, the ANA indicated a licensed nurse documented Resident A had a fall risk. During a review of Resident A’s base line CPs, date 3/6/2019, there was no CP to address Resident A’s risk for falls. During a review of Resident A’s Fall Risk Assessment (FRA) dated 3/7/2019, the FRA indicated Resident A was at high[GA3][BM4] risk for fall. During a review of Resident A’s Licensed Progress Notes (LPN), dated 10/4/2019 and timed at 2 p.m., the LPN indicated at 1:58 p.m., Certified Nurse Assistance 1 (CNA 1) heard Resident A yelling and crying and the call light was on. The LPN indicated upon CNA 1 entering Resident A’s room CNA 1 found Resident A face down on the floor and with the help of another staff member Resident A was put back into the bed. The LPN indicated Resident A had a bump on her forehead, an abrasion (an area damaged by scraping or wearing away) on her nose and her nose was bleeding. According to the LPN, 911 (emergency services) was called and Resident A was transferred to a GACH. During a review of the GACH Emergency Record (ER), dated 10/4/2019, the ER record indicated a computerizes tomography ([CT scan]) special x-ray to create detailed pictures) was done of Resident A’s head. The CT scan indicated there was a fracture to Resident A’s nasal bone with overlying soft tissue swelling. According to the GACH’s discharge[GA5] note, Resident A was discharged back to the facility on 10/4/2019 with a follow-up to be done with the resident's primary care physician. During an interview on 12/13/2022 at 10:30 a.m., with the Director of Nurses (DON), the DON was asked what the importance was of having a care plan for falls and the DON replied it was important for all staff on every shift to know how to provide care to Resident A and other residents. During a review of the facility's P/P titled, “Care Plans, Comprehensive Person-Centered,” dated 12/2016, the P/P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. The facility failed to: 1. Ensure the licensed nurses developed a CP for the risk for falls for Resident A, who was assessed as being at high risk for falls. 2. Ensure the licensed nurses adhered to the facility’s policy and procedure (P/P) titled, “Care Plans, Comprehensive Person-Centered,” which stipulated a comprehensive, person-centered care plan is developed and implemented for each resident. As a result, Resident[GA6] A fell on 10/4/2019, required a transfer to a general acute care hospital (GACH) on the same day and was diagnosed with a fractured (broken bone) nose. These violations had a direct or immediate relationship to the health, safety, or security of Resident 1 [GA1]Please add the date of the fall and transfer [GA2]What was the resident ADL’s status. Helpful to add if he was dependent [GA3]Was at high or moderate risk for falls? The failure statement indicated -high [BM4R3]High Risk per the Fall Risk assessment on 3/7/2019 [GA5]Date of dc note [GA6]Please add the date of the fall and transfer