Failure to Include Essential Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included essential medication instructions for a resident within 48 hours of admission, as required by facility policy. Specifically, the baseline care plan for a female resident with multiple diagnoses, including Type 2 Diabetes Mellitus and Peripheral Arterial Disease, did not include her prescribed insulin and anticoagulant medications, despite physician orders and administration records confirming their use. The omission was confirmed through record review and interviews with staff, including the MDS nurse, LVN, and DON, all of whom acknowledged that such medications should be included in the baseline care plan to ensure proper care. The resident's admission records indicated she was cognitively intact and had significant medical needs requiring careful medication management. The facility's own policy and staff interviews confirmed that baseline care plans must include all necessary medications and be completed within 48 hours of admission. However, the review of the resident's baseline care plan showed that insulin and anticoagulant medications were not documented, and this was acknowledged by the DON during the survey. The failure to include these medications in the baseline care plan constituted a deficiency in meeting professional standards of quality care.