Failure to Complete Baseline Care Plan for New Admission with Dialysis Needs
Penalty
Summary
Facility staff failed to complete a Baseline Care Plan within 48 hours of admission for a resident who was admitted with complex medical needs, including a renal diet, fluid restriction, and scheduled dialysis treatments. Record review showed that the resident's hospital discharge orders included specific instructions for a renal diet, a 1500 ml daily fluid restriction, and dialysis three times a week via a hemodialysis catheter. However, the Baseline Care Plan initially created did not address these critical care needs, including dialysis and medication information. Interviews with facility staff, including an LPN and the MDS Coordinator, confirmed that the Baseline Care Plan only included information on code status, behavioral issues, and pressure ulcer management, but omitted essential details related to the resident's dialysis and other immediate care requirements. The MDS Coordinator was unaware of the resident's dialysis status at the time the Baseline Care Plan was developed, and additional care areas were only added later after the omission was discovered.