Failure to Develop Timely Baseline Care Plan for Anticoagulant and Pain Management
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a resident's anticoagulant therapy and pain medication within 48 hours of admission. The resident was admitted with a history of deep vein thrombosis, pulmonary embolism, avascular necrosis of the lower extremities, and was on chronic opiate therapy for pain. Admission orders included Xarelto for anticoagulation and both scheduled and PRN narcotic and non-narcotic pain medications. Despite these orders, the baseline care plan did not include goals or interventions for either anticoagulant therapy or pain management. Interviews with nursing staff and administration revealed that the baseline care plan was typically completed by the Unit Manager, who was not present on weekends. As a result, if a resident was admitted on a Friday evening, the baseline care plan would not be completed until the following Monday, unless the Unit Manager was available. In this case, the baseline care plan was not completed within the required timeframe due to the Unit Manager's absence and the facility's ongoing annual survey. The new weekend supervisor was not aware of the requirement to complete baseline care plans on weekends, contributing to the deficiency.