MACON, GA- CHERRY BLOSOM HEALTH AND REHABILITATION

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20243

Based on observation, record review, interviews, and a review of the facility policy titled, Skilled Nursing Services Patient’s Plan of Care and ADL [Activities of Daily Living] Plan of Care, the facility failed to develop and implement comprehensive person-centered care plans for three residents (R) (50,112, and 44) of 20 sample residents reviewed for care plans. R50 did not have a comprehensive care plan addressing dental needs, vision, and bed rails; R112 did not have a comprehensive care plan addressing dental needs, restorative services, and pain management; and R44 did not have a comprehensive care plan addressing bed rail use.

Findings include:
Review of the facility’s policy titled Skilled Nursing Services Patient’s Plan of Care with a review date of 12/20/22, revealed the facility had a policy to ensure that each patient would have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient’s medical, physical, mental, and psychosocial needs.

1. Record review of the admission Minimum Data Set (MDS) for R50 dated of 07/30/2023 located in the MDS tab of the EMR, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 12 (indicating moderate cognitive impairment). R50was coded as having adequate vision, no broken teeth or tooth fragments, and was able to move about in bed with assistance and transfer with the help of two persons. Record review of the care plan for R50 in the Electronic Medical Record (EMR) revealed no dental needs care plan, vison care plan, or bed rail care plan.

Observation on 09/19/2023 at 12:21 pm quarter rails were observed on R50’s bed. In an interview, R50 stated she was unable to use them. R50 stated that she needed a dental appointment but could not pay for it and needed a follow up appointment for her vision. R50 stated that she previously saw an eye doctor and thought she was supposed to have cataract surgery but had not been told what would happen. R50 stated she had difficulty with her vision and had closed the blinds over the window to keep the glare out.

Interview on 09/21/23 at 10:28 am the Director of Nurses (DON) stated she would look for R50’s care plans for dental, vision and bed rail. No care plans were presented.

2. Record review of the admission MDS for R112 dated 09/03/2923 located in the MDS tab of the EMR revealed a had a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). The MDS revealed that the resident had pain almost constantly, pain affected her daily activities and her ability to sleep at night. The worst pain was rated as a 10 on a one to 10 scale. Review of the Care Area Assessment (CAA) revealed pain was triggered for further assessment. R112’s pain disturbed her sleep, limited day to day activities, and limited independence with at least some activities of daily living. She received insufficient pain relief as pain relief occurred, but the duration was not sufficient, resulting in breakthrough pain. The CAA further revealed dental was triggered for care planning. Resident had broken teeth which she stated happened last year-resident denied pain/discomfort. The resident saw a dentist prior to admission to the facility and would see the resident while in facility. The resident did have Diabetes Mellitus (DM) and took medication which could impact oral health.

Record review of care plan under in the EMR revealed there was no care plan for dental needs.

Interview on 09/21/2023 at 10:28 am the Director of Nurses (DON) stated she would look for

R112’s dental care plan. No care plan was presented.

Record review of the Medication Administration Record (MAR) for R112 dated 09/2023 revealed R112 expressed pain several times during the month rated at 10 out of 10, and tramadol (pain medication) was given as ordered to address the pain. Medication order for tramadol 50 mg (milligram) tablet give one tablet by mouth every eight hours as needed for pain with a start date of 09/04/2023.

Interview on 09/19/2023 at 11:28 am, with R112 stated that her dental bridge broke during a fall prior to admission and that she could feel the screws remaining from the bridge in her mouth. R112 stated that she took pain medication and that there had not been any facility action yet to make a dental appointment.

Record review of the nurses’ notes tab in the EMR revealed on 09/20/2023, the resident was complaining of the screws on the bridges in her mouth hurting her mouth. The note documented, Will inform oncoming nurse and put on clinical dashboard that resident needs to see a dentist asap [as soon as possible].

Review of the comprehensive care plan, located in the EMR, revealed no care plan addressing the resident’s pain management needs.

Interview on 09/21/2023 at 10:28 am the Director of Nursing (DON) stated she would look for R112’s pain care plan and confirmed there should have been a plan addressing R112’s pain. No care plan was presented.

Record review of R112’s Physical Therapy (PT) note found under Therapy tab in EMR dated 08/29/2023 revealed R112 had a past medical history reason for referral. R112’s PT evaluation was completed on 08/29/2023. R112 was referred for skilled PT for establishment of restorative program to further maintain current functional status.

Record review of the restorative flowsheet dated 09/01/2023-09/18/2023 for R112 in the EMR revealed a plan for OMNICYCLE training for BLE (bilateral lower extremity) strengthening and coordination x 15-20 minutes with 0-2 resistance. Provide rest periods as needed. Documentation for 15 minutes was completed on 09/02/2023-09/14/2023, and 09/17/2023.There was no documentation on 09/15/2023-09/16/2023, and on 09/18/2023.

Record review of the care plan located in the EMR revealed no restorative care plan.
Interview on 09/21/2023 at 10:28 am the DON stated she would look for R112’s restorative care plan. No care plan was presented.28154

Review of the facility’s policy titled ADL [Activities of Daily Living] Plan of Care, reviewed 12/30/22, showed: Intent. Develop and communicate patient needs for assistance with ADLs. Guideline.

-Resident’s ADL needs are assessed on admission and are addressed on the Baseline Care Plan and communicated to staff.
-Nursing develops the patient’s ADL care plan and will communicate the level of assistance required for the patient.

-The ADL care plan will be updated in conjunction with the comprehensive care plan as required per
regulatory and RAI [Resident Assessment Instrument] guidance and with changes in patient needs.

3. Record review of the EMR for R44 revealed a medical diagnoses that included quadriplegia, anxiety disorder, and major depressive disorder.

Record review of the most recent quarterly MDS dated [DATE] revealed R44 had a BIMS of 11 indicating moderate cognitive impairment.

Observation and interview on 09/19/2023 at 10:19 am, R44’s bed was noted to have bilateral assist bars on her bed. R44 stated she didn’t use them.

Record review of the care plan for R44 located in the EMR showed a focus of limited mobility due to quadriplegia and was noted to require assistance with moving from a lying to a sitting position at the side of the bed but did not include any interventions noting the use of bed assist bars for bed mobility.