Failure to Develop Timely and Comprehensive Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop adequate baseline care plans within the required timeframe for four recently admitted residents, resulting in a lack of continuity of care. For one resident with a recent stroke, diabetes, chronic kidney disease, and heart failure, there was no documentation in the care plan or Kardex regarding the use of a right wrist brace, its purpose, who was responsible for its application, or how long it should be worn. Additionally, the care plan did not address the resident's primary physical problems and functional limitations associated with heart failure, nor did it include the resident's goals or interventions to achieve those goals. Another resident admitted with chronic kidney disease, heart failure, ventricular fibrillation, and a defibrillator had no care plan addressing the treatment for DVT prevention, the presence of a defibrillator, or the associated physical problems and interventions. Similarly, a resident with end-stage renal disease requiring dialysis had a care plan that failed to document the dialysis schedule, the dialysis center's contact information, or specific interventions related to dialysis, despite relevant orders being present in the medical record. A fourth resident with a hip fracture and irritable bowel syndrome (IBS) with constipation had no care plan focus on their IBS diagnosis, bowel monitoring, or related interventions, even though the resident experienced ongoing bowel issues and received medications for both constipation and diarrhea. Staff interviews confirmed that these care plan omissions were not in line with facility expectations and should have been addressed.