Surveyors found that the facility failed to develop an adequate baseline care plan within 48 hours of admission for a resident with complex respiratory disease, diabetes, and anticoagulant therapy. Although admission orders included multiple respiratory medications, continuous O2, insulin on a sliding scale, and apixaban, the baseline care plan only listed general discharge and functional goals and did not address respiratory status, diabetes management, or anticoagulant use. Comprehensive care plans were created for pain, falls, self-care deficit, skin integrity, and nutrition, but none were developed for the resident’s respiratory condition, diabetes, or anticoagulant therapy during the stay.
A resident admitted with STEMI, CHF, atrial fibrillation, chronic embolism and thrombosis of deep veins, and hypertensive heart disease with heart failure had anticoagulant therapy changed from Eliquis to Xarelto per the hospital discharge summary, and Xarelto was ordered by the physician on admission. However, the baseline care plan created within 48 hours did not list the anticoagulant among current medications and did not include a care plan for anticoagulant therapy. The DON confirmed the resident was receiving Xarelto at admission and that it should have been included in the baseline care plan.
Failure to provide a baseline care plan summary to a resident was identified during record review. Documentation showed that a baseline care plan had been initiated, but there was no record that it was reviewed or that a copy was given to the resident or the responsible party, and the DON was unable to locate proof that it had been provided.
Surveyors found that two residents were admitted without completion of required baseline care plans (BLCPs) within 48 hours and without documentation that BLCP summaries and current medication lists were provided to them or their representatives. The DON reported that residents are supposed to receive a BLCP at admission, with a copy given within 48–72 hours, and that staff should document provision of the BLCP in a progress note. For these two residents, no BLCPs or BLCP summaries were found in the medical records, and there was no documentation that they or their representatives had received them.
Facility staff failed to complete BLCPs within the required timeframe and did not document that the BLCP summary and current med list were given to the resident or representative. For some residents, care plans were created or discussed out of sequence with the MDS process, and the record lacked evidence that copies of the care plans were provided to the resident or family.
Missing Dementia Baseline Care Plan: A resident with unspecified dementia, severe cognitive impairment, and no behaviors was observed in bed being fed breakfast and appeared pleasantly confused. Record review showed the baseline care plan did not include a patient-centered comprehensive care plan for dementia care, and the DON and NHA agreed no dementia care plan was present.
Failure to provide and document baseline care plans for two residents. The facility stated BLCPs were completed within 24 to 48 hours of admission and should be resident-specific, include key care areas such as pain, falls, skin, and ADLs, and be given to the resident or family with a signed receipt in the chart. However, review of the paper chart and EMR for two residents found no BLCPs or signature pages, and MR staff could not locate the records. LPN interviews also showed uncertainty about whether the BLCP was provided or documented.
A resident was admitted without having a baseline care plan completed and signed within the required 48 hours. Review of the medical record showed that the baseline care plan, which is intended to outline how to provide care for a new resident and is required to be created within 48 hours of admission, was not finalized until more than two weeks after the admission date. The resident’s representative confirmed this delay, and the DON acknowledged that facility policy and requirements call for baseline care plans to be completed, signed, and provided to the resident or representative within 48 hours of admission.
A resident admitted for rehabilitation did not have a baseline care plan reviewed or provided to their representative within 48 hours of admission. The required care plan, which should include initial goals, physician orders, therapy, dietary, and social services, as well as admission medications, was not documented as given or discussed with the representative. Both the DON and the resident confirmed the representative was not included in the care planning process as required.
Two residents and their representatives did not receive a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission. In both cases, documentation was incomplete or missing, and staff interviews revealed uncertainty about responsibility for providing this information.
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