Failure to Develop Baseline Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as R212, within 48 hours of admission, as required by regulations. Resident R212 was admitted with multiple diagnoses, including unspecified mood disorder, dementia, kidney failure, and a history of transient ischemic attack, among others. The resident exhibited behaviors such as refusal of care, medications, and verbal aggression, which were documented in nursing notes over several days. Despite these documented behaviors, there was no evidence of a baseline care plan addressing these issues. The resident was admitted to the facility on November 22, 2024, and discharged on November 27, 2024, due to behaviors and safety concerns. During the resident's stay, they consistently refused medications, care, and meals, and exhibited aggressive behavior. A psychological consultation was conducted, and a new medication order was obtained, but the resident continued to refuse care. The lack of a baseline care plan was confirmed during an interview with a licensed nurse, who acknowledged the resident's behavior concerns and the absence of a care plan addressing these issues.
Plan Of Correction
1. R212 is no longer a resident at the facility. 2. An audit was completed for new admissions and readmissions from 12/24/24 to 1/24/25 to assure that the residents had a baseline care plan developed. 3. Education was completed with licensed nurses on the requirements for ensuring a baseline care plan is developed. 4. The DON/Designee will audit new admissions and readmissions weekly x 4 weeks then monthly x 2 months to assure that baseline care plans are developed in a timely manner. Findings of the audits will be reported to monthly QA x3.