Failure to Develop Baseline Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a baseline care plan in accordance with its own policy and procedures for one resident. Record review showed that the resident was admitted and later readmitted with diagnoses including stroke, generalized weakness, and diabetes mellitus. The resident's Minimum Data Set indicated cognitive impairment and dependence on staff for activities of daily living. Despite these needs, there was no baseline care plan developed to address the resident's specific conditions, including the management of a gastrostomy tube (g-tube). Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the absence of a care plan could result in staff not having unified or appropriate interventions for the resident, particularly regarding the risk of g-tube dislodgement. The facility's policy required a comprehensive, person-centered care plan to be developed for each resident to meet their health, safety, psychosocial, behavioral, and environmental needs, but this was not done for the resident in question.