Failure to Develop and Share Adequate Baseline Care Plan for Resident With Pain and Pressure Ulcer
Penalty
Summary
Surveyors found that the facility failed to develop and implement an adequate baseline (48-hour) care plan for a newly admitted resident with significant pain and a chronic pressure ulcer, and failed to provide a summary of that plan to the resident or representative. On admission, nursing assessment documented that the resident had frequent moderate pain over the prior five days, rated 5/10, which made it hard to sleep and limited day-to-day activities. The assessment also identified a wound on the coccyx, described as an opening on the right buttock, and progress notes documented admission with a chronic Stage IV sacral ulcer. A PT evaluation noted that pain interfered with functional activity and sleep and indicated that nursing would address the pain. A provider progress note and subsequent pain ratings showed ongoing pain scores ranging from 5/10 to 8/10 over the first several days after admission. Despite these findings, the 48-hour baseline care plan dated two days after admission only indicated that the resident experienced pain, without including any interventions to relieve that pain. The baseline care plan also noted the resident was on Enhanced Barrier Precautions related to wounds but did not document that the resident had skin issues or specify interventions to treat the wounds. The care plan further failed to indicate whether the resident or the resident’s family/representative was offered a copy of the 48-hour care plan or given the opportunity to sign it. Staff interviews confirmed that pain, pressure ulcers, and related interventions should be included on the baseline care plan and that residents should be offered a copy and the opportunity to sign. The facility’s own baseline care plan policy stated that the baseline care plan should include any services and treatments to be administered by the facility until a comprehensive assessment and person-centered care plan are developed.
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