Failure to Accurately Complete Baseline Care Plans for Immediate Resident Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that accurately reflected the immediate needs of two residents. For one resident admitted with end stage renal disease (ESRD) requiring dialysis and chronic respiratory failure requiring continuous oxygen therapy, the baseline care plan did not document the need for dialysis or oxygen use, despite these needs being clearly indicated in the hospital discharge summary, physician orders, and clinical orders. The care plan instead marked that the resident was not receiving dialysis and did not check the box for oxygen usage. Interviews with staff confirmed that the baseline care plan should have included these needs, and that missing or inaccurate information could result in improper care. Another resident was admitted with a history of cerebral infarction, dysphasia, and Alzheimer's disease, and had a moderate cognitive impairment. The baseline care plan for this resident did not include any goals or interventions for staff to use when communicating with the resident, despite clear evidence of significant speech difficulties and dysarthria. Observations and interviews with staff revealed that the resident struggled to communicate, was often not understood by staff, and became frustrated as a result. The care plan and supporting documentation did not indicate the resident's speech impairment, and staff acknowledged that the assessment tools used did not adequately capture or communicate the resident's communication needs. Facility policy required that a baseline care plan be developed and implemented within 48 hours of admission, including all initial goals and interventions based on admission and physician orders, therapy services, and other relevant information. However, the facility did not ensure that the baseline care plans for these residents included the minimum necessary healthcare information to properly care for them, specifically omitting critical needs related to dialysis, oxygen therapy, and communication strategies for speech impairment. Interviews with facility leadership and staff confirmed that these omissions were not in line with expectations and could result in residents not receiving appropriate care.