Failure to Develop and Communicate Resident-Centered Baseline Care Plan
Penalty
Summary
The facility failed to develop and communicate a resident-centered baseline care plan to address the immediate needs of a newly admitted resident within 48 hours of admission, as required by policy. The resident, who had a history of a recent fall, adjustment disorder, type 2 diabetes, and congestive heart failure, was admitted with intact cognition and no skin conditions noted on the initial evaluation. However, the baseline care plan incorrectly indicated that the resident did not have any wounds, despite the presence of dressings on the coccyx and bilateral heels. Staff interviews revealed that the admitting nurse did not perform a full skin assessment due to the resident's refusal to remove hospital dressings after a long commute, and documented 'no wounds' on the baseline care plan because the form did not allow for additional comments. Further review showed that the resident and family expressed concerns about the lack of preparation for the resident's diabetic dietary needs and wound care. The wound care nurse later identified and treated wounds on the coccyx and heels, including a deep tissue injury and excoriation, which were not initially care planned. Staff interviews confirmed that the baseline care plan was not updated to reflect the resident's actual condition, and the DON acknowledged the limitation of the form and the need for resident-specific care planning, particularly regarding wounds.