Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with significant medical needs, including chronic congestive heart failure, a history of pneumonia, and acute respiratory failure with hypoxia. Upon review, it was found that the resident had physician orders for oxygen therapy and albuterol as needed for shortness of breath, and required varying levels of assistance with daily activities. Despite these needs and orders, the electronic health record did not contain a baseline care plan addressing the management of the resident's respiratory and cardiac conditions or the interventions required for shortness of breath. Interviews with nursing staff and the Director of Nursing confirmed that a baseline care plan was not created as required by facility policy, which mandates such a plan within 48 hours of admission to ensure proper care and communication among staff. The absence of this care plan was acknowledged by staff as having the potential to delay necessary care and services for the resident, as it failed to provide guidance on managing the resident's immediate medical and physical needs.