Failure to Develop Baseline Care Plan Addressing Pain Management Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted female resident with chronic pain syndrome and multiple bone disorders. Upon admission, the resident was assessed with a pain level of 4/10 and had physician orders for pain management, including a Fentanyl patch, Baclofen, and PRN oxycodone. Despite these documented needs, the baseline care plan did not include any entries related to pain or pain management. The resident reported experiencing significant pain, delays in receiving pain medication, and issues with medication administration, such as the removal of her Fentanyl patch without timely replacement and receiving Baclofen at undesired times. Interviews with the resident, MDS Coordinator, and DON confirmed that the baseline care plan was not completed as required and did not address the resident's immediate needs, particularly pain management. The facility's care planning policy did not specifically address baseline care plans, and staff acknowledged that the lack of a comprehensive baseline care plan could result in staff not knowing how to manage the resident's pain effectively.