Failure to Establish Baseline Care Plans for High-Risk Admissions
Penalty
Summary
The facility failed to provide appropriate baseline care planning for two residents upon admission, specifically neglecting to address high-risk focus areas. One resident was admitted with Parkinson's disease and dysphagia, and was found to have a BIMS score indicating cognitive impairment. Despite these conditions, there was no baseline care plan in place to address the resident's difficulty swallowing and associated high risk of choking. Another resident was admitted with a diagnosis of Enterococcus bacteremia and was receiving intravenous antibiotics via a PICC line. This resident was cognitively intact, but the care plan did not include a baseline focus on the management and risks associated with the PICC line, such as potential complications and infections. Interviews with facility staff confirmed that baseline care plans should have been established for both residents to address their specific high-risk needs. The facility's policy requires that care plans incorporate goals and objectives based on comprehensive assessments and that these plans be accessible to all disciplines. However, the absence of baseline care plans for these residents' critical conditions represented a failure to meet immediate care needs as required by facility policy and regulatory standards.