Failure to Develop Resident-Centered Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a resident-centered baseline care plan for one resident within 48 hours of admission. The resident, who was observed sitting in a wheelchair with wraps on both legs due to a lower leg infection, reported experiencing pins and needles from his toes to his hips and stated that staff changed his leg wraps every couple of days. He also indicated that he used a sit-to-stand lift for transfers and was working with therapy to regain strength. Review of the baseline care plan revealed that a template was used, but it did not specify the amount of assistance required for functional activities, nor did it address the resident's use of a lift for transfers or the need for dressing changes related to his leg infection. Staff interviews confirmed that the nurse was responsible for completing the care plan template and that physical therapy would revise it as needed, but the necessary individualized details were missing.