Failure to Develop and Implement Person-Centered Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan that accurately reflected a resident's condition and provided person-centered care within 48 hours of admission. Upon review, the baseline care plan for a newly admitted male resident with multiple complex diagnoses, including hemiplegia, quadriplegia, morbid obesity, respiratory failure, and several wounds, was found to be incomplete and lacking specific instructions for effective care. The care plan only included general interventions for skin integrity, such as applying barrier cream and assisting with repositioning, without addressing the resident's specific wounds and other immediate needs. Record reviews revealed that the resident was admitted with several skin issues, including an abrasion to the abdomen and elbow, unstageable pressure ulcers on the foot and heel, and a fungal infection. Physician orders and treatment administration records indicated multiple wound care interventions and the use of pressure-reducing devices, but these were not fully incorporated into the baseline care plan. Interviews with staff confirmed that the care plan did not detail all necessary interventions, with the MDS nurse stating that a general statement to provide skin/wound care as ordered was considered sufficient, despite the presence of multiple wounds and specific physician orders. Further interviews with facility staff, including the DON and MDS nurse, revealed that the process for developing baseline care plans relied on minimal information and ongoing updates, rather than ensuring a comprehensive and individualized plan within the required 48-hour window. Facility policy required that baseline care plans be individualized and based on interdisciplinary assessments, but this was not followed in the resident's case, resulting in a care plan that did not accurately depict the resident's condition or provide clear guidance for staff.