Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, as required by §483.21(a)(1)-(3). Resident R90 was admitted with diagnoses of high blood pressure, hyperlipidemia, and lymphedema, but a review of their clinical record on March 13th revealed no baseline care plan had been developed. The Director of Nursing confirmed this oversight during an interview on the same day. Similarly, Resident R203, admitted with chronic obstructive pulmonary disease, chronic respiratory failure, and dependence on supplemental oxygen, also lacked a baseline care plan within the required timeframe. A review of their medical record on March 11th confirmed the absence of a baseline care plan, which was acknowledged by the Director of Nursing during an interview. These findings indicate a failure to comply with the regulatory requirement to establish a baseline care plan promptly for new admissions.
Plan Of Correction
The facility is unable to complete baseline care plans for R90 and R203. A comprehensive care plan was developed for R90 and R203. Moving forward, the facility will ensure a baseline care plan is developed. To identify other residents that have the potential to be affected, the RNAC/designee reviewed new admissions for 2 weeks to ensure a baseline care plan was developed. Negative findings will be addressed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed staff and RNAC on the regulatory requirements of F655. To monitor and maintain ongoing compliance, the RNAC/designee will audit new admission baseline care plans 2x weekly x4 weeks then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.