Failure to Include Critical Medications and Dietary Preferences in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included all necessary instructions to provide effective and person-centered care for two residents within 48 hours of admission. For one resident with heart failure and atrial fibrillation, the baseline care plan did not include the use of prescribed anti-coagulant and anti-platelet medications, despite physician orders for Apixaban and Clopidogrel Bisulfate. The MDS nurse indicated that these medications were not automatically triggered by the baseline care plan assessment and was unsure if they should be included, even though they have significant side effects that require monitoring. For another resident admitted with a femur fracture and irritable bowel syndrome, the baseline care plan did not initially include the resident's preference for a Kosher diet, despite a physician order specifying this dietary requirement. The intervention for a Kosher diet was not added to the care plan until five days after admission. Interviews with facility staff confirmed that baseline care plans are initiated by the DON and completed by the admitting nurse, and are due within 48 hours of admission, but did not consistently address all physician and dietary orders as required by facility policy.