Failure to Develop Baseline Care Plan for Resident with PICC Line
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with a peripherally inserted central catheter (PICC line). The resident's admission record indicated diagnoses of obstructive hydrocephalus, type 2 diabetes mellitus without complications, and malignant neoplasm of the brain. Upon admission, the resident had a right antecubital PICC line, which was intact and showed no signs of infection. The Minimum Data Set (MDS) assessment documented that the resident had moderately impaired cognitive skills and required substantial to maximal assistance with daily activities, and was dependent for several self-care tasks. The MDS also confirmed the presence of a central line (PICC) on admission. Interviews with facility staff, including the DON and the MDS Coordinator, confirmed that a baseline care plan addressing the resident's PICC line care, including dressing changes, site monitoring for infection, and assessment, was not created within the required 48-hour timeframe. The facility's policy and procedure required a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, but this was not followed in the resident's case. The absence of a baseline care plan resulted in the resident not receiving appropriate care, monitoring, and assessment specific to the PICC line.