Failure to Develop Accurate and Complete Baseline Care Plans on Admission
Penalty
Summary
Surveyors identified a failure to create accurate baseline care plans containing the minimum health information necessary to properly care for newly admitted residents. For one resident with COPD, cirrhosis, critical illness myopathy, permanent atrial fibrillation, and nicotine dependence, observation showed she removed an upper denture and had missing, broken, or decayed lower teeth. However, her baseline care plan documented that she had her own teeth and did not indicate the presence of an upper denture or other dental issues. In an interview, the DON acknowledged that the resident’s upper denture and dental issues should have been included on the baseline care plan. For another resident admitted with schizophrenia, bipolar disorder, bacteremia, syphilis, MDR Pseudomonas, third-degree burn of the left lower limb, cannabis and stimulant use, and psychoactive substance use, the baseline care plan noted partial weight-bearing status with two-person assist and the presence of multiple scabs and burns. Despite this, the plan did not include instructions for wound or injury care, did not address the resident’s constant pain rated at 5, did not include interventions for identified fall risk, did not address the resident’s infection, and did not include information related to the use of ordered antipsychotic medication (Olanzapine 5 mg daily for schizophrenia). The ICN confirmed the resident was admitted with Morganii and CRAB, had an open wound, and was on transmission-based precautions, and the DON confirmed that the baseline care plan did not include the minimum healthcare information necessary to properly care for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.