Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing the immediate needs of three newly admitted residents within 48 hours of admission, as required by facility policy. For each resident, medical records and hospital discharge summaries identified specific immediate care needs, such as management of new onset seizures, respiratory support, nutritional requirements via nasogastric tube, major depression with psychotropic medication use, chronic pain management, diabetes, COPD, congestive heart failure, and dietary restrictions. However, there was no documentation that baseline or comprehensive care plans were created or implemented to address these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Floor nurses and nursing supervisors indicated it was not their responsibility, while the Unit Manager acknowledged it was her duty but admitted to missing required care needs for at least one resident. The DON was unaware that baseline care plans had not been completed in a timely manner, despite facility expectations that all residents have a complete baseline care plan within 48 hours of admission.