Failure to Develop Baseline Care Plan for New Admission with Surgical Wound
Penalty
Summary
A newly admitted resident with a recent left below-the-knee amputation (BKA) and a history of atherosclerosis and peripheral vascular disease was not provided with a baseline care plan to address his immediate medical needs upon admission. Observations revealed that the resident experienced bleeding through his surgical dressing, which soiled his sheets, and both he and his wife reported the issue to several staff members. Despite these reports, the resident did not receive a dressing change until the bleeding had stopped on its own. A review of the resident's medical record confirmed the absence of a baseline care plan addressing his post-surgical wound care needs. Facility policy requires that an interdisciplinary baseline care plan be developed within 48 hours of admission to address immediate health and safety needs, including physician's orders and resident-centered interventions. The lack of such a care plan for this resident resulted in a failure to promptly address his surgical wound care needs during the critical initial period following admission.