Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident, identified as R149, within the required 48-hour timeframe following admission. The resident was admitted with multiple diagnoses, including COPD, Centrilobular Emphysema, Generalized Anxiety Disorder, Alcohol Dependence, Depression, Acute Pancreatitis, and Anemia. Despite having physician orders for medications such as Lidocaine Patch, Eliquis, and Gabapentin, the facility did not create a baseline care plan that included these orders or any other necessary healthcare information to properly care for the resident. The only care plan in place for the resident addressed an ADL self-care performance deficit, which was initiated eight days after admission. This delay in developing a comprehensive person-centered care plan was confirmed by the Unit Manager, Employee E3, during an interview. The lack of a timely baseline care plan and comprehensive care plan for Resident R149 represents a failure to meet the regulatory requirements for comprehensive person-centered care planning.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The care plan for Resident R149 was updated to include goals and interventions for the residents specific goals and needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents will be conducted to ensure that a baseline care plan was developed and implemented and that a written summary of the baseline care plan was provided to the resident and/or resident representative. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff and Interdisciplinary Team regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five clinical records to ensure that a baseline care plan was developed and that the resident/ resident representative received a copy of the baseline care plan. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.