Failure to Include Essential Needs in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary instructions to provide effective and person-centered care for three of seventeen sampled residents. Specifically, observations revealed that multiple residents were receiving oxygen therapy, but their baseline care plans did not address problems, goals, or interventions related to oxygen use. One resident, who also had a urinary catheter due to urinary retention and required extensive assistance with activities of daily living (ADLs) because of a cancer diagnosis, did not have these needs reflected in the baseline care plan. Interviews with staff confirmed that baseline care plans were initiated at admission but did not consistently include all required information for continuity of care. Staff acknowledged that areas such as ADLs, pain, urinary issues, falls, psychotropic medications, and oxygen therapy should be included, but these were sometimes omitted. Additionally, staff noted that some aspects of the computer system used for care plan entry needed to be addressed to ensure thorough completion of baseline care plans.