Failure to Develop Accurate Baseline Wound and Nutritional Care Plans
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that accurately reflected a resident’s identified conditions and physician orders. Policy and procedure required a baseline care plan within 48 hours that included minimum health care information and interventions for special needs such as wound care and dietary orders. The resident was admitted with severe cognitive impairment and an initial skin assessment documented 10 pressure injuries and wounds, including pressure injuries to the sacrococcygeal area, hips, gluteal fold, heel, side of the right foot, a surgical incision with separated wound edges, a skin tear on the right arm, and open wounds on the right knee and left ear. Despite these findings, review of the baseline care plan initiated shortly after admission showed no care plan addressing pressure injuries or wounds. During interviews, the IP, an LVN, and the DON each confirmed that no wound care plan had been developed for any of the resident’s wounds, and all stated that each wound should have its own care plan with specific interventions and goals, and that the absence of such a plan could compromise or jeopardize the resident’s plan of care. The facility also failed to create an accurate baseline nutritional care plan consistent with the resident’s NPO status and enteral feeding orders. Physician orders documented that the resident was NPO and receiving enteral tube feedings, and a swallowing evaluation noted loss of liquids/solids from the mouth, residual food after meals, and coughing or choking during meals or when swallowing medications. A physician progress note further documented that the resident was nonverbal, NPO, and fed via GT. However, the nutritional care plan developed for the resident included interventions such as honoring food preferences, offering substitutes if less than 50% of the meal was eaten, and allowing ample time to eat and drink, which implied oral intake. In an interview, the DON confirmed that the nutritional care plan did not reflect the physician’s NPO and enteral feeding orders and acknowledged that the care plan was incorrect and could have led staff to believe the resident was able to take food or water by mouth, with a stated risk of aspiration into the lungs if oral intake occurred.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with multiple medical conditions, including a documented stage II coccyx pressure ulcer present on admission, did not have this pressure ulcer reflected in the baseline care plan. Although a Comprehensive Skin Evaluation identified the ulcer and the resident was assessed as cognitively intact, the baseline care plan omitted the pressure ulcer and contained no related interventions. During interviews, the DON and an MDS coordinator confirmed that the care plan did not address the ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission.
The facility failed to provide baseline care plan summaries to residents and/or their representatives and did not clearly base initial goals on admission orders. In one case, a resident with dementia had a care conference documented as including medication review and an offer of a care plan copy, but the resident’s POA reported no recall of medication discussion or receiving a copy, and there was no evidence a copy was given to the POA. In another case, a resident with multiple chronic conditions and high ADL dependence reported that medications and treatments were not reviewed, was not asked if she wanted a copy of the care plan, and was not asked about or provided compression hose previously used for edema. Staff confirmed that copies of baseline care plans were not routinely provided unless requested and that documentation did not show review of physician, medication, treatment, or dietary orders, and the facility policy did not address giving residents a copy of the baseline care plan.
A resident admitted with severe cognitive impairment, total care dependency, and multiple serious diagnoses did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. Staff confirmed that no baseline care plan was in place to guide immediate care for this resident.
Two residents admitted with complex medical conditions did not have complete baseline care plans developed within 48 hours of admission. Only partial care plans, such as dietary or nutrition/hydration risk, were initiated, while other required care plans were delayed. Facility leadership confirmed that care plans were not completed in accordance with policy, and care conference documentation was incomplete.
A resident with dementia, behavioral issues, and a history of aggression was admitted without an individualized care plan or documented interventions for behaviors, despite known concerns and diagnoses. The DON expressed reservations about the admission and no immediate strategies were communicated to CNAs or implemented to address the resident's behavioral needs.
A resident admitted with anoxic brain damage and post-traumatic seizures did not receive a baseline care plan summary within 48 hours of admission, despite having intact cognition and requiring staff assistance with ADLs. Interviews confirmed the resident was not informed about his care plan, and facility policy requiring resident participation and documentation was not followed.
Failure to Include Existing Pressure Ulcer in Baseline Care Plan
Penalty
Summary
The facility failed to ensure the baseline care plan reflected a resident’s current status of having a pressure ulcer and to create and implement a plan to meet the resident’s immediate needs within 48 hours of admission. The resident was admitted with diagnoses including gastrostomy, gastrojejunal ulcer, cognitive communication deficit, unspecified atrial flutter, and malignant neoplasm of the prostate, and was documented as cognitively intact on the most recent MDS 3.0 assessment. A Comprehensive Skin Evaluation completed shortly after admission identified a stage II pressure ulcer to the coccyx that was present on admission. However, the baseline care plan developed for the resident did not list the stage II pressure ulcer and contained no interventions related to the pressure ulcer, despite facility policy requiring a baseline plan of care to meet immediate health and safety needs within 48 hours of admission. During interview, the DON and MDS Coordinator confirmed that the care plan did not address the resident’s pressure ulcer and that no interventions were in place for this condition. This deficiency was cited as non-compliance under the referenced complaint number.
Failure to Provide and Review Baseline Care Plan Summaries With Residents/Representatives
Penalty
Summary
The facility failed to provide a summary of baseline care plans to residents and/or their representatives and did not ensure that baseline care plans were clearly based on admission orders. For one resident with Alzheimer’s disease and dementia who was confused and oriented only to person, the medical record showed an admission assessment and a multidisciplinary care conference where staff documented that medications were discussed and that a copy of the plan of care was offered. However, the resident’s power of attorney (POA) reported not recalling any discussion of medications as part of the admission care conference and not being offered or given a copy of the baseline care plan. The Social Service Designee confirmed that the form only allowed staff to mark that a copy was offered to or received by the resident, that the resident was very confused with poor vision, and that there was no evidence a copy of the baseline care plan was provided to the POA. For another resident with multiple diagnoses including COPD, ventilator dependence, chronic respiratory failure, morbid obesity, heart failure, diabetes, and significant functional dependence, the multidisciplinary care conference form indicated that admission, goals, therapy, discharge, health, and code status were discussed, that the plan of care was reviewed, and that the resident was offered a copy of the plan of care. The form did not show that initial goals were based on admission orders or that physician orders, including dietary orders, were reviewed. The resident stated that medications and treatments were not reviewed at the conference, that she was not asked if she wanted a copy of the care plan, and that no one asked about or provided compression hose, which she had used at a prior facility for edema. The Social Service Designee verified that the facility did not provide copies of baseline care plans unless requested and that there was no documentation of physician orders, medications, treatments, or dietary orders being reviewed during the meeting. The facility’s care plan policy required resident or sponsor signatures to verify presence and review of the care plan but did not address providing a copy of the baseline care plan as required by regulation.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident within 48 hours of admission, as required by facility policy. Medical record review showed that the resident was admitted with diagnoses including intracranial hemorrhage, respiratory failure, and COPD, and was assessed as severely cognitively impaired, dependent for all care, and at risk for pressure ulcers. Despite these significant care needs, there was no baseline care plan developed or implemented for the resident. This was confirmed during staff interview with the Regional Registered Nurse, who verified the absence of a baseline care plan upon admission. The facility's policy states that a baseline care plan must be developed within 48 hours to provide effective and person-centered care.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. For one resident admitted with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy, only the dietary care plan was initiated within the required timeframe, while the remainder of the care plan was not completed until several days later. The care conference for this resident occurred after admission, but there was no evidence of a baseline care plan being established within 48 hours as required. Another resident admitted with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, and heart failure, also did not have a complete baseline care plan within 48 hours. Only a nutrition/hydration risk care plan was initiated, with no other care plans documented. Additionally, the care conference summary for this resident lacked signatures from the resident, family, or representative, indicating incomplete involvement. Interviews with facility leadership confirmed that the care plans for both residents were not completed fully or in a timely manner, contrary to facility policy.
Failure to Implement Individualized Behavioral Care Plan Upon Admission
Penalty
Summary
The facility failed to ensure that an individualized care plan addressing behavioral issues was in place for a resident admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. Upon admission, the resident was known to have inappropriate behaviors and was resistive to care, as documented in the care plan. However, the interventions for these behaviors were not communicated to the Certified Nursing Assistants (CNAs) via the Kardex or CNA report sheets, and there was no documentation of behavioral interventions or management strategies for wandering. Interviews revealed that the Director of Nursing (DON) had concerns about admitting the resident due to behavioral issues noted in hospital records, but no interventions were implemented to address these concerns upon admission. Further interviews indicated that the DON was not present at the time of admission and did not support the decision to admit the resident, citing the facility's lack of a behavior unit and the resident's history of aggressive behavior and need for antipsychotic medication. Despite a referral for psychiatric services being made after admission, there was a lack of immediate action to address the resident's behavioral needs within the first 48 hours. The deficiency was identified during a complaint investigation and affected one resident out of those reviewed for care plans.
Failure to Provide Baseline Care Plan Summary Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and provide a baseline care plan summary to a resident within 48 hours of admission, as required by policy. Medical record review showed that the resident, admitted with diagnoses including anoxic brain damage and post-traumatic seizures, did not receive a summary of the baseline care plan upon admission. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Interviews with the resident and the Social Services Director confirmed that the resident was not provided with a summary of the baseline care plan and could not recall any meeting regarding his care. Facility policy requires that residents be informed of and participate in their care planning, with documentation of the discussion or viewing of the care plan. This process was not followed for the resident in question.
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