Baseline Care Plan Lacked Critical Respiratory Information for New Admission
Penalty
Summary
The facility failed to ensure that the baseline care plan for a newly admitted resident included sufficient information to provide person-centered care. Specifically, the baseline care plan did not document the resident's significant respiratory conditions, which included pneumonia, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), dependence on oxygen, chronic bronchitis, and the use of a BiPAP machine. These omissions were identified through a review of the resident's face sheet, physician orders, and the baseline care plan in the electronic medical record (EMR). Further review of the resident's five-day Minimum Data Set (MDS) confirmed that the resident was cognitively intact, experienced shortness of breath when lying flat, required continuous oxygen, and utilized a BiPAP machine. During an interview, the Regional Nursing Director acknowledged that the resident's respiratory diagnoses and the BiPAP order were not included in the baseline care plan. This lack of documentation meant that the baseline care plan did not contain the minimum healthcare information necessary to properly care for the resident as required by facility policy.