Failure to Develop Accurate and Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was accurate and complete within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan should be developed for each resident within 48 hours of admission and should include instructions needed to provide effective, person-centered care. Review of the resident's admission record revealed diagnoses including end stage renal disease (ESRD), and observations showed the resident had a gastrostomy tube (G-tube), a central venous catheter (CVC), and a continuous positive airway pressure (CPAP) machine. However, the care plan in the electronic medical record (EMR) only included a focus for dialysis with interventions for peritoneal dialysis, which was incorrect, as the resident was receiving hemodialysis via a CVC. Further review and interviews confirmed that the care plan lacked documentation for the resident's G-tube and CPAP use. The LPN verified that the care plan did not reflect the correct type of dialysis and omitted the G-tube and CPAP. The Infection Preventionist/Unit Manager and the Director of Nursing also confirmed these omissions and inaccuracies in the care plan, verifying that the resident's care needs were not properly documented as required by facility policy.