Failure to Initiate Baseline Care Plan for Resident with Ileostomy
Penalty
Summary
The facility failed to initiate a baseline care plan within 48 hours of admission for a resident who had an ileostomy, as required by facility policy and procedure. Upon admission, the resident's medical records, including a hospital discharge summary, indicated specific instructions for ostomy care, hydration, and monitoring of intake and output to prevent dehydration. Despite this, the facility did not develop a baseline care plan addressing the resident's ileostomy care or the necessary nutritional interventions to maintain or prevent weight loss. Interviews with facility staff, including an LVN and the DON, confirmed that the resident's intake and output were not monitored and that a baseline care plan for ileostomy care was not initiated. The lack of a baseline care plan meant that essential information for the resident's care was not documented or implemented, contrary to the facility's own admission policy and procedures.