Failure to Develop Baseline Care Plan for Pain Management Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy and professional standards. The resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disease (COPD), orthopedic aftercare, presence of a right artificial hip joint, history of malignant neoplasm of the ovary, and osteoarthritis. Despite these complex medical needs, there was no evidence that a baseline care plan was completed to address the resident's immediate needs, particularly regarding pain management, within the required timeframe. Record review showed that the resident had an active physician order for Oxycodone 10 mg every 4 hours as needed for severe pain, starting from the day of admission. However, the baseline care plan did not include instructions or interventions for pain management within the first 48 hours. The resident reported receiving the medication as ordered until being informed by nursing staff that the order was only for three days, after which the medication was withheld. The lack of a timely baseline care plan resulted in the resident experiencing unmanaged pain, which prevented participation in therapy.