Failure to Develop Baseline Care Plan for Pain and Anticoagulant Use
Penalty
Summary
The facility failed to develop a baseline plan of care within 48 hours of admission for a newly admitted resident, as required by facility policy. Specifically, the interdisciplinary team did not include care plans for pain management or anticoagulant use, despite the resident's documented medical history and current physician orders. The resident had a history of venous thrombosis, embolism, and hypertension, and was observed wearing a lidocaine patch for chronic right knee pain. Physician orders indicated the resident was receiving meloxicam and topical lidocaine for pain, as well as an anticoagulant medication. A review of the resident's baseline care plan revealed that neither pain management nor anticoagulant use was addressed. During an interview, the DON confirmed that these care needs should have been included in the baseline care plan. The deficiency was identified through clinical record review, observation, staff and resident interviews, and facility policy review.