Failure to Initiate Baseline Care Plan
Penalty
Summary
Pinecrest Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the development and implementation of a baseline care plan for residents. The facility policy mandates that a baseline care plan should be developed for each resident within 48 hours of admission. However, it was determined that the facility failed to initiate a baseline care plan for one resident, identified as Resident R99, who was admitted on January 9, 2025. The resident's clinical record, which included diagnoses such as diabetes, high blood pressure, anemia, and acute kidney injury, lacked evidence of a baseline care plan being initiated. During an interview, the Nursing Home Administrator confirmed the absence of a baseline care plan in Resident R99's clinical record. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The failure to initiate a baseline care plan for Resident R99 indicates a lapse in adhering to the facility's policy and federal regulations, which require the development of a person-centered care plan within 48 hours of a resident's admission.
Plan Of Correction
1. Resident R99's base line care plan was developed. 2. An audit will be completed on all admissions in the last 30 days to ensure a base line care plan was developed within 48 hours and provided to the resident and/or his/his representative. Any deficient practice will be corrected. 3. All licensed nursing employees will be reeducated on the facility policy titled "Care Plan: Baseline Interdisciplinary Plan of Care." 4. An audit will be completed by the Quality Director or designee on all new admissions to ensure that the baseline care plan is developed and implemented within 48 hours of admission and given to the resident and/or his/her representative. These audits will be completed weekly for one month, monthly for two months, and quarterly thereafter. These results will be reported quarterly to the Quality Assurance Performance Improvement Committee. 5. Corrective Action date will be April 10, 2025.