Failure to Develop Baseline Care Plan for Immediate Post-Surgical Needs
Penalty
Summary
The facility failed to develop a baseline care plan that addressed the immediate care needs of a newly admitted resident within 48 hours of admission. The resident, who was alert and oriented upon arrival, had a midline surgical incision closed with a VAC dressing and required specific wound care and antibiotic therapy as ordered by the physician. The orders included checking the wound VAC settings and connections every four hours and administering two antibiotics, Amoxicillin and Clarithromycin, twice daily for surgical aftercare. Despite these documented care needs, there was no evidence that a baseline care plan was created to address the resident's wound VAC management or antibiotic administration. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan did not include the necessary information for the resident's wound care and antibiotic use.