Incomplete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a newly admitted male resident with diagnoses including chronic gout, emphysema, and adjustment disorder with anxiety. The baseline care plan was missing several required elements, such as a precautionary plan for fall risk, dietary instructions for a No Added Salt diet, prescribed PRN pain medications, routine medications, physician treatment orders for moisture associated skin damage (MASD), and prescribed therapy services. Additionally, the resident and his representative were not provided with a summary of the baseline care plan as required. Record reviews showed that the resident had significant pain, requiring administration of tramadol, and was receiving allopurinol for gout. Interviews with the DON and Regional Director of Clinical Services confirmed that the baseline care plan was incomplete and that a copy had not been provided to the resident or his representative. The administrator acknowledged that the baseline care plan was not properly completed and that this was the responsibility of the DON. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all necessary instructions and a summary provided to the resident or representative, which was not done in this case.