Failure to Develop and Accurately Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with chronic respiratory failure and hypoxia. Upon review, it was found that no baseline care plan was present in the resident's medical record. Staff interviews revealed that the responsibility for completing baseline care plans fell to the admitting nurse, especially during weekends. The Director of Nursing noted that computer system changes during a facility acquisition contributed to the issue, but confirmed that the admitting nurse was still responsible for ensuring the care plan was completed. Additionally, the facility did not ensure that a baseline care plan accurately addressed insulin use for a newly admitted resident with diabetes. The baseline care plan for this resident did not indicate the diagnosis of diabetes or the administration of insulin, despite physician orders for insulin therapy. The Admission/Discharge Nurse acknowledged the omission, and both the DON and Administrator confirmed that baseline care plans are expected to accurately reflect residents' diagnoses and medications.