Failure to Timely Develop and Implement Person-Centered Baseline Care Plan for CHF Management
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of congestive heart failure (CHF). Upon admission, the resident's Minimum Data Set (MDS) assessment and physician orders indicated the need for weight monitoring due to CHF, with specific instructions to weigh the resident daily, then weekly, and then monthly. However, the baseline care plan created did not include specific parameters for when to notify a physician about weight changes, which is critical for CHF management. The care plan only directed staff to take daily weights without providing guidance on thresholds for physician notification regarding weight gain, a key indicator of fluid retention in CHF patients. Additionally, the baseline care plan was not developed and implemented within the required 48-hour timeframe after admission. Documentation showed inconsistent weight monitoring, and there was no evidence that the physician was contacted when the resident experienced significant weight gain. Interviews with the resident, nurse manager, and director of nursing confirmed that the baseline care plan lacked necessary weight parameters and was not completed on time. The facility's own policy required the development of a baseline care plan within 48 hours, including instructions necessary to provide effective and resident-centered care, but this was not followed in the resident's case.