Failure to Develop and Implement Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with multiple complex medical conditions. The facility's policy requires a baseline care plan to be created within 48 hours to address immediate health and safety needs, including initial goals, physician and dietary orders, therapy and social services, and any relevant recommendations. However, for one resident recently admitted with diagnoses such as coronary artery disease, chest pain, COPD, diabetes, neuropathy, acute and chronic pain, peripheral artery disease, recent lower extremity bypass surgery, surgical incisions, arterial wound, and stage 2 pressure ulcers, the baseline care plan did not include goals or interventions for these conditions. Observation revealed the resident had active bleeding through a dressing on the left lower extremity and reported being on two anticoagulants. Review of the clinical record showed multiple active physician orders for pain management, COPD, chest pain, DVT prophylaxis, blood glucose monitoring, and wound care. Despite these needs, the baseline care plan lacked evidence of interventions for the resident's cardiac issues, anticoagulant use, COPD, diabetes, pain, wound care, nutrition, or therapy services. These concerns were confirmed during an interview with the Director of Nursing.