Failure to Include Critical Admission Care Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that included all care concerns present at the time of admission for one resident. The resident was admitted with multiple significant diagnoses, including chronic obstructive pulmonary disease with exacerbation, chronic ischemic heart disease, bacteremia, heart failure, chronic kidney disease stage four, atrial fibrillation, and obstructive sleep apnea. Upon admission, the resident had active physician orders for intravenous antibiotics (ampicillin sodium and ceftriaxone) to treat an implantable cardioverter-defibrillator (ICD) infection, required the use of a wearable cardioverter defibrillator (life vest) with specific battery and placement checks, and had a peripherally inserted central catheter (PICC) line with associated care instructions. A review of the baseline care plan dated the day of admission revealed that it did not address the PICC line, life vest, infection, or the administration of antibiotics, all of which were present and required care from the time of admission. The Director of Nursing confirmed in an interview that these care needs were present on admission and should have been included in the baseline care plan, but were not.
Plan Of Correction
F-0655 Baseline Care Plan Resident #96 Baseline care plan did not include instructions to provide effective and person-centered care on 6/10/25 by the Director of Nursing. An initial audit was conducted on all new residents on 6/10/25 by the Director of Nursing and all Baseline Care Plans were completed. All clinical staff were educated on 6/10/25 on baseline care plans needing to be completed on admission by the Director of Nursing. The Director of Nursing or Designee will conduct an audit on all new Residents for 4 weeks to ensure Baseline Care Plans reflect all minimum healthcare information needed to provide effective person-centered care. Any unusual findings will be forwarded to the QAPI committee for prompt resolution. The Director of Nursing will monitor this area for compliance on an ongoing basis.