Failure to Complete Baseline Care Plan with Hospice and DNR Status
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a resident who was admitted for hospice respite care. The baseline care plan did not include essential information such as hospice status and Do Not Resuscitate (DNR) code status, despite these being present in the resident's physician orders and relevant to her care. The resident had significant medical conditions, including hemiplegia, hemiparesis following a cerebral infarction, chronic viral hepatitis C, type 2 diabetes, and dysphagia, and was admitted and discharged under hospice care. The resident was rarely or never understood, as indicated by the MDS assessment, and required person-centered care planning to address her complex needs. Interviews with facility staff, including the ADON, DON, SS nurse, and MDS coordinator, revealed that the omission of hospice and DNR status from the baseline care plan was due to oversight and lack of proper documentation. Staff acknowledged that the information should have been included and that the baseline care plan is used to guide care and inform staff of critical care instructions. The facility's policy required the development and implementation of a baseline care plan to provide effective and person-centered care, but this was not followed in this instance.