Failure to Develop Baseline Care Plans for Residents with Oxygen Therapy and Anticoagulant Orders
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with significant medical needs. For one resident admitted with diagnoses including pneumonia, chronic respiratory failure, and COPD, there was a physician order for oxygen therapy at 2 liters per minute via nasal cannula three times a day. Despite these orders and the resident's intact cognitive status, no baseline care plan addressing oxygen therapy was created or implemented. Both the registered nurse and the director of nursing confirmed that a baseline care plan should have been in place to address the resident's primary respiratory issues and to serve as a communication tool for coordinated care. For another resident admitted with chronic embolism, thrombosis, atrial fibrillation, and atherosclerosis of the aorta, there was a physician order for the anticoagulant Pradaxa to be administered twice daily. This resident had severe cognitive impairment and was identified as being on a high-risk drug class. Despite the order for anticoagulant therapy, no baseline care plan was developed to address the use of Pradaxa, including monitoring for adverse effects and identifying interventions to manage potential complications. The registered nurse acknowledged that a baseline care plan should have been initiated upon admission to ensure proper monitoring and care. The facility's policy and procedure on baseline care plans, last reviewed in January 2025, requires that a baseline plan of care be developed within 48 hours of admission to meet each resident's immediate health and safety needs. This plan must include initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The failure to develop and implement these baseline care plans for the two residents resulted in a deficiency related to the timely provision of essential healthcare services.