Failure to Develop Timely Baseline Care Plan and Fall Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with significant medical needs, including weakness, cerebral edema, intracerebral hemorrhage, acute respiratory failure with hypoxia, and abnormal gait and mobility. The resident was identified as a high fall risk due to balance problems, chronic health issues, debility, cognitive impairment, and difficulty moving or propelling herself in a wheelchair. Despite these risk factors, the admission assessment and baseline care planning were incomplete, and no fall risk interventions were documented or communicated effectively to staff. Observations and interviews revealed that the admitting nurse did not complete the necessary sections of the admission assessment related to fall risk, and the baseline care plan lacked focus, goals, and interventions for fall prevention. The Kardex system, which should have served as a reference tool for staff, did not reflect fall precautions or interventions, and staff were not adequately trained in its use or in updating and referencing it. Communication breakdowns were evident, as CNAs relied on verbal reports rather than documented care plans or Kardex information, and several staff members were unaware of how to access or update care plans. As a result of these systemic failures, the resident was left alone in her room while up in her wheelchair, leading to a fall in which she hit her head and required hospitalization. The lack of a timely and comprehensive baseline care plan, incomplete documentation, and insufficient staff training and communication placed the resident at risk for serious harm. The facility's policies required prompt assessment and care planning, but these were not followed in this case.
Removal Plan
- Review charts of all admissions/readmissions for completion of the admission/readmission assessment and baseline care plans.
- Audit all residents' care plans to validate accuracy of each resident's ADL care needs.
- Educate Director of Nursing Services, Assistant Director of Nursing, and Reimbursement Nurses on the process for validating the completion of all admission/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
- Educate Director of Nursing Services, Assistant Director of Nursing, and Reimbursement Nurses on Abuse/Neglect and Residents Rights.
- Provide education to all licensed nurses on the process of completion of admissions/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
- Ensure all licensed nurses on leave, agency, or PRN staff are in-serviced prior to working their shift.
- Ensure administrative nursing staff provide in-service/education prior to team members working their assigned shift.
- Ensure all residents who require respiratory care are provided such care.
- Audit all residents' care plans to validate accuracy of each resident's ADL care needs.
- Provide education to all licensed nurses on the process of completion of admissions/readmissions and the completion of the baseline care plan to ensure it includes effective and person-centered care that meets professional standards of quality care.
- Conduct skills validations of accuracy and completion of admissions/readmission/baseline care plans of nurses.
- Review all admission/re-admission orders in the clinical meeting to validate accuracy and completion of admission/readmission/baseline care plans.
- Place this plan and all education and auditing tools in a binder and keep with the Administrator or Director of Nursing Services.
- Report findings of observations to the QAPI committee during monthly meetings.