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F0655
D

Failure to Develop Baseline Care Plan for Resident

Verona, Pennsylvania Survey Completed on 01-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a baseline care plan for Resident R156 within 48 hours of admission, as required by their policy. Resident R156 was admitted with diagnoses of dementia, benign prostatic hyperplasia, and depression. An observation revealed that the resident was in his room sitting in a wheelchair with a Foley catheter bag attached to the chair. However, the baseline care plan did not include interventions for the care of the Foley catheter. This omission was confirmed during an interview with an LPN, who acknowledged that the baseline care plan for Resident R156 was incomplete.

Plan Of Correction

The R156 care plan was updated to indicate that the resident has a Foley catheter. R156 was not affected by the deficient practice of failure to include a Foley catheter in the line care plan. The LNAC/designee will educate team members on the need to include catheters in the baseline care plan. The LNAC/designee will conduct weekly audits for four weeks of baseline care plans for newly admitted residents to ensure necessary resident care information is present on the care plan. The audit results will be submitted to the QAPI committee for review for any trends and the need for any performance improvement plans.

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