Failure to Develop and Communicate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement person-centered baseline care plans and provide summaries to residents and/or their responsible parties within 48 hours of admission for multiple new admissions. In several cases, essential medical needs and physician orders were not reflected in the baseline care plans. For example, one resident admitted with urinary retention and an order for an indwelling urinary catheter did not have catheter use documented in the baseline care plan. Another resident with end stage renal disease and a physician order for a wearable defibrillator (LifeVest) did not have this device included in their baseline care plan. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these omissions occurred and that the care plans should have included these critical interventions. Additionally, the facility did not ensure that baseline care plans and medication lists were reviewed with residents or their responsible parties, nor did they provide copies of these documents within the required timeframe. In several instances, there was no documentation that the care plan or medication list was reviewed or provided, even for residents with cognitive impairment or those whose responsible parties were available. Interviews with staff revealed confusion regarding responsibility for reviewing and distributing these documents, with some agency nurses believing it was the facility staff's duty, and facility staff not consistently completing all required sections or providing the necessary information to residents and families. The deficiency was identified for five residents admitted with various diagnoses, including urinary retention, end stage renal disease, intracerebral hemorrhage, and a fracture. In each case, the baseline care plan was either incomplete, missing critical information, or not communicated to the resident or responsible party as required. The DON acknowledged that nurses were not consistently completing all sections of the baseline care plan or ensuring that residents and responsible parties received and reviewed the care plan and medication summary within 48 hours of admission.