Failure to Develop 48-Hour Admission Care Plan for Cardiac Management
Penalty
Summary
The facility failed to develop and implement a care plan within 48 hours of admission that addressed a resident's cardiac disease, cardiac medications, and ordered vital sign monitoring. The resident was admitted on March 5, 2026, at 15:20 with multiple diagnoses, including hypertension, non-traumatic intracerebral hemorrhage, hemiplegia and hemiparesis of the non-dominant side, tracheostomy, gastrostomy, respiratory failure, diabetes mellitus, and aphasia. The physician ordered vital signs to be monitored every shift and prescribed several cardiac-related medications, including amlodipine besylate and lisinopril for hypertension, aspirin for prophylaxis, atorvastatin for hyperlipidemia, Eliquis for cerebrovascular accident, and metoprolol tartrate for hypertension. Clinical record review showed that the required care plan was not developed within 48 hours of admission and did not include health care related to the resident's cardiac disease, the use of cardiac medications, or parameters for vital sign monitoring. An interview with the DON confirmed the absence of a care plan addressing these areas for this resident. The deficiency was cited under 28 PA. Code 211.12(d)(5) for nursing services.
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