Inaccurate Baseline Care Plan Documentation
Penalty
Summary
The facility failed to ensure that the baseline care plan for one resident was accurate and reflected the resident's actual care needs. Upon review, the baseline care plan for a resident admitted for respite care contained another individual's name in the recreation (activity) care plan section. Additionally, the self-care deficit care plan included information about colostomy care, which was not applicable to the resident in question, as confirmed by the physician's progress note and staff interviews. During joint record reviews and interviews, both the registered nurse responsible for formulating the baseline care plan and the Director of Nursing acknowledged that the care plan contained inaccurate information, including references to another person and care needs not relevant to the resident. Both staff members confirmed that the care plan is part of the resident's medical record and must accurately reflect the resident's clinical status, which was not the case in this instance.