Failure to Timely Develop and Document Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to provide evidence that a baseline care plan was developed in a timely manner for a resident admitted with multiple complex medical conditions, including hypertension, iron deficiency anemia, bronchiectasis, atrial fibrillation, dementia, severe malnutrition, diabetes, pressure ulcers, enterocolitis due to clostridium difficile, open wound, and end stage renal disease. The resident's medical record review showed that the handwritten baseline care plan document lacked a date of completion, signature, or identification of the person who completed it. Additionally, there was no indication that the resident or their representative received a copy of the baseline care plan. Further review revealed that comprehensive care plans for several critical focus areas, such as nutrition and hydration risk, end-stage renal disease and hemodialysis, hypertension, fall risk, activities of daily living self-care deficit, incontinence, renal failure, clostridium difficile, pain, polypharmacy, discharge planning, and others, were not initiated within 48 hours of admission as required. The DON confirmed that baseline care plans were always completed on paper, not in the electronic health record, and verified the lack of documentation and communication regarding the baseline care plan for this resident.