Failure to Develop and Implement Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a resident with complex medical needs and a high risk for falls. Upon admission, the resident had diagnoses including nontraumatic acute subdural hemorrhage, hemiplegia, generalized muscle weakness, and a history of transient ischemic attack. The resident's fall risk assessment indicated a high risk, with contributing factors such as incontinence, impaired gait and balance, recent hospitalization, and predisposing conditions like stroke and arthritis. Despite these findings, the baseline care plan created did not address essential areas such as initial goals based on admission orders, physician and dietary orders, therapy and social services, fall risk, fall prevention interventions, or assistance needs related to activities of daily living, bed mobility, or call light use. The care plan only included the resident's personal interests. Progress notes documented that the resident was lethargic and had ongoing concerns about bleeding risks and supervision needs, as expressed by her son. The resident experienced a non-witnessed fall and was transported to the emergency room, but there was no documentation that the baseline care plan was reviewed or revised following the incident. Further notes indicated the resident was unable to use the call light independently and required staff repositioning, yet these needs were not reflected in the care plan. Interviews with facility staff, including the Unit Manager, Administrator, and DON, confirmed that the expectation was for a complete baseline care plan to be in place within 48 hours, and that the resident's high fall risk should have been addressed in the care plan. However, staff were unaware that a complete plan had not been developed. The resident's son reported that he had communicated his concerns about his mother's fall risk, sedation, and inability to move independently to the nursing staff, and had requested bed rails. He was notified by the facility after his mother fell out of bed and was sent to the emergency room. The resident did not return to the facility after the hospital visit. Staff interviews further confirmed that the resident's high fall risk and need for frequent checks and repositioning were not adequately care planned, and that the required baseline care plan was not completed within the mandated timeframe.