Failure to Develop Baseline Care Plan for IV Therapy and Infection
Penalty
Summary
The facility failed to develop a baseline care plan that addressed the immediate needs of a resident within 48 hours of admission, as required by facility policy. The resident was admitted with acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease, and was observed receiving oxygen therapy. The resident also had a midline IV catheter for antibiotic administration due to an infection. During interviews, the resident reported issues with the IV catheter, including needing to leave the facility for a replacement, and confirmed ongoing antibiotic treatment. Upon review, it was found that the baseline care plan did not include interventions or care planning for the IV catheter or the infection. The Unit Manager and MDS Nurse both confirmed that the care plan lacked documentation and planning for these critical needs, despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission and to include all necessary instructions for person-centered care, including special needs such as IV therapy. The deficiency was identified through observation, interview, and record review.