Failure to Develop Baseline Care Plan for IV Access Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted for rehabilitation care due to a urinary tract infection and required intravenous antibiotics. Upon admission, the resident was noted to have severe cognitive impairment and an intravenous line in place for administration of meropenem, a broad-spectrum antibiotic. However, the baseline care plan did not include any interventions or instructions to support the resident's intravenous access, despite documentation in the nursing progress notes and physician's orders indicating the need for IV therapy. Interviews with facility leadership confirmed that the omission was not identified during interdisciplinary team reviews, and the MDS nurse did not document the IV access in the care plan template. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, including all necessary information to meet the resident's immediate healthcare needs. The lack of a documented plan for IV access meant that staff did not have clear guidance on how to manage this critical aspect of the resident's care.