Failure to Develop Timely Baseline Care Plan Including Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who was admitted with a minimally displaced zone 1 sacral fracture and required an indwelling catheter. Upon review, there was no documentation of Enhanced Barrier Precautions (EBP) in the resident's care plan or Kardex, despite signage on the resident's door and staff awareness that EBP was required due to the indwelling catheter. Interviews with staff confirmed that EBP should have been included in the baseline care plan, but it was not documented until five days after admission. The resident was cognitively intact, as indicated by a perfect BIMS score, and was aware that staff sometimes wore gowns when providing care but did not know the reason. Facility policy requires the interdisciplinary team to collect and record data for the admission baseline care plan within 24 hours and to develop and implement the baseline care plan within 48 hours of admission. The lack of timely documentation and implementation of EBP in the baseline care plan resulted in the potential for unmet care needs for the resident.