Failure to Develop Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure that baseline care plans were developed for three residents, which included necessary information regarding their immediate care needs. The facility's policy required that a baseline care plan be initiated upon admission and completed within 48 hours, individualized to each resident. However, for Resident 89, who required a feeding tube for nutritional support, there was no documented evidence of a baseline care plan addressing the need for Enhanced Barrier Precautions (EBP) due to the feeding tube. Similarly, Resident 94, who had a Foley catheter for urinary retention, also lacked a baseline care plan addressing EBP needs. Additionally, Resident 95, who had a Foley catheter and was on anticoagulant and diuretic medications, did not have a baseline care plan that included EBP needs. Interviews with the Nursing Home Administrator and the Assistant Campus Director confirmed the absence of these baseline care plans for the residents' specific care and treatment needs. The facility's failure to develop these plans was identified during a review of facility policies, clinical records, and staff interviews.
Plan Of Correction
Resident 89, 94 and 95 had no adverse reactions related to not having a baseline care plan demonstrating the need for enhanced barrier precautions (EBP), anticoagulants or diuretics. Resident 89 is no longer in the facility. Resident 94 is no longer in the facility. Resident 95 is no longer in the facility. A facility-wide sweep of all foley catheters, feeding tubes, anticoagulants and diuretics was conducted to ensure that a baseline care plan was initiated with the related items in place. Any issues identified were corrected at time of discovery. The registered assessment coordinator (RNAC) and all licensed nursing staff were re-educated regarding updating the baseline care plan with enhanced barrier precautions (EBP) for foley catheters and feeding tubes as well as to demonstrate the use of anticoagulants and diuretics. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that the baseline care plan is initiated and the proper related items are in place, weekly X4 weeks, and then monthly X2 months. Identified issues will be addressed at time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.