Failure to Develop Baseline Care Plan for Resident with Tracheostomy
Penalty
Summary
The facility failed to develop a baseline care plan for a resident, identified as Resident R1, who was admitted with significant medical needs. According to the facility's policy, an individualized, interdisciplinary care plan should be initiated within 24 hours of admission. However, upon review of Resident R1's clinical records, it was found that no baseline care plan was developed for the resident's tracheostomy care. This oversight was confirmed during an interview with the Director of Nursing. Resident R1 was admitted to the facility with a tracheostomy and had a physician's order for supplemental oxygen via trach mask. The resident's Minimum Data Set indicated diagnoses of cancer, malnutrition, and muscle weakness. Despite these complex medical conditions, the facility did not create a baseline care plan within the required timeframe, which is a violation of the regulatory standards for comprehensive person-centered care planning.
Plan Of Correction
F 655 - Resident 1 has been discharged from the facility. No corrective action can be completed. An audit of the last ten admissions will be completed by the Director of Nursing, or designee, to ensure baseline care planning is completed accurately. Education will be provided to the nursing staff by the Director of Nursing, or designee, on the expectation of baseline care planning to be completed at the time of the resident's admission. New admissions will be audited by the Director of Nursing, or designee, for two months to ensure the baseline care plan is completed accurately. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Director of Nursing shall ensure compliance.