Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who had a colostomy and a diagnosis of Type 2 Diabetes Mellitus with hyperglycemia. The baseline care plan did not include instructions or interventions related to the resident's colostomy care or diabetes management, despite these being documented in the resident's medical records and physician orders. The omission was identified through record review, observation, and interviews, which confirmed that the baseline care plan lacked necessary information to address the resident's specific health needs. Interviews with the DON and MDS Coordinator revealed that the charge nurse responsible for admitting the resident did not include the required diagnoses and care instructions in the baseline care plan. Both staff members acknowledged that the baseline care plan should have addressed the resident's medical devices and diagnoses, and that the failure to do so meant staff did not have the information needed to provide appropriate care. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all relevant diagnoses and care needs, but this was not followed in this instance.