Failure to Include Fall Risk and Pain Management in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that addressed a newly admitted resident’s immediate needs related to fall prevention and pain management. Record review showed the resident had diagnoses of chronic neck pain, chronic pain syndrome, mild dementia, severe major neurocognitive disorder, debility, and impaired mobility. Hospital documentation indicated a recent cognitive and functional decline, increased confusion, difficulty ambulating with a walker, generalized weakness, and reduced mobility. On admission, the facility’s fall risk evaluation identified the resident as being at high risk for potential falls, with instructions that fall prevention protocols should be initiated immediately and documented on the care plan. Physician orders at admission included PRN acetaminophen extended release for pain and a daily lidocaine 4% patch for lower back pain. Despite this information, the baseline care plan completed within 48 hours of admission did not include goals or interventions for the resident’s chronic pain syndrome and did not address the resident’s immediate needs related to fall risk prevention. The MDS nurse who completed the baseline care plan stated it included transfer status, therapy, and dietary information and believed it met minimum requirements for basic safety. The resident’s representative reported that the resident had a history of chronic pain requiring medication for comfort, that his pain continued after admission, and that she believed he was at high risk for falls due to his physical and mental condition, and wanted staff to be aware of these issues. The DON and Administrator both stated that a baseline care plan should include the minimum healthcare information necessary to meet a resident’s needs, and the DON acknowledged that the resident’s high fall risk and pain should have been included, but they were not.
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