Failure to Develop Baseline Care Plan for Hemodialysis
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for a resident's immediate care needs, specifically related to hemodialysis. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission, including necessary healthcare information to provide effective and person-centered care. However, for one resident, who was a new admission from the hospital and required hemodialysis three times a week, there was no documented evidence of a baseline care plan addressing their hemodialysis care and treatment needs. The resident had specific physician orders related to their hemodialysis treatment, including checking the AV fistula site daily for bleeding and monitoring for a bruit and thrill. Despite these orders, the facility did not develop a baseline care plan to address these critical care needs. This deficiency was confirmed during an interview with the LPN Assessment Coordinator, who acknowledged that a baseline care plan was not developed for the resident's hemodialysis care needs.
Plan Of Correction
Preparation and submission of this Plan of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Resident #94 care plan was reviewed at the time of the survey by the interdisciplinary team and will be revised/updated as needed. To identify other residents with the potential to be affected, the Minimum Data Set (MDS) nurse/designee will audit new admissions over the last 30 days to ensure that a baseline care plan was generated within 48 hours of admission, and reflected instructions needed to provide effective care to the resident based on physician orders and resident preferences/goals. To prevent a future occurrence, the Director of Nursing/designee provided education to the MDS nurses on the baseline care plan policy. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to ensure baseline care plans are generated within 48 hours of admission and include information regarding resident's immediate care needs. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.