Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to implement baseline care plans for three residents who required enhanced safety monitoring upon admission. Each resident's baseline care plan specified the need for 1:1 staff care and 15-minute safety checks due to cognitive concerns, recent surgeries, or a history of falls. However, observations, interviews, and record reviews revealed that these interventions were not carried out as documented. For example, one resident with a recent craniotomy and sepsis was admitted for rehabilitation and required close monitoring, but there was no documentation or evidence of 1:1 care or 15-minute checks, and the resident experienced a fall within hours of admission. Staff interviews indicated a lack of awareness and understanding regarding the care plan requirements. Nursing staff reported that 1:1 care and 15-minute checks were not feasible due to staffing limitations, and some staff were unaware that these interventions were listed in the care plans. Residents also reported that staff only entered their rooms for routine tasks such as delivering medications or meals, and not for the specified safety checks. Continuous observation confirmed that residents were not receiving the required monitoring, as staff did not enter their rooms at the prescribed intervals. Further interviews with facility leadership and staff revealed confusion about how the 1:1 care and 15-minute checks were included in the care plans. The Director of Nursing and Social Worker were uncertain about the origin of these interventions in the plans, and the Administrator stated that such checks were meant as examples rather than actual directives. The facility's policy required a baseline care plan to be implemented within 48 hours of admission to address immediate needs, but the documented interventions were not followed, leading to a failure to meet the residents' immediate safety needs as outlined in their care plans.