Failure to Develop Baseline Care Plan for Complex Medical Needs
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for a resident with multiple complex medical needs. Specifically, there was no BCP created for diabetes management, despite physician orders for regular blood sugar monitoring and insulin administration. Additionally, the BCP did not address the use of an abdominal binder, which was being used to prevent the resident from pulling on a gastrostomy tube. The absence of these care plans was confirmed during interviews and record reviews with facility staff, who acknowledged that the required BCPs were missing. Furthermore, the BCP interventions for the resident's NPO (nothing by mouth) status were not appropriate. The care plan included instructions to monitor meal intake and to offer warm beverages, which were not suitable for a resident who was NPO and receiving nutrition via a G-tube. Staff interviews confirmed that these interventions were incorrect and should have been individualized to the resident's needs. As a result of these deficiencies, the resident was transferred to the hospital for elevated blood sugar and required admission for fluids and diabetes control.