Failure to Initiate Baseline Care Plan and Address Pain Management Upon Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for a newly admitted resident with multiple complex medical conditions, including heart failure, respiratory disease, several pressure ulcers, spinal and lumbar pain, adult failure to thrive, and urinary retention requiring a catheter. At the time of the survey, the resident's admission Minimum Data Set (MDS) assessment had not been completed, and no baseline care plan had been initiated. The resident reported experiencing significant pain, particularly at the site of the urinary catheter, and stated that the pain management provided was ineffective. She also indicated that staff had not discussed her pain goals with her. Interviews with the ADON and DON confirmed that the resident had been experiencing frequent and high levels of pain since admission, and that a resident-specific care plan addressing pain had not been completed. The facility was unable to provide a care plan policy when requested. These findings demonstrate that the facility did not assess or address the resident's immediate needs, particularly regarding pain management, within the required 48-hour timeframe following admission.