Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours of admission, as required. The resident, a male with diagnoses including acute on chronic systolic heart failure, chronic kidney disease, and chronic obstructive pulmonary disease, was admitted with physician orders and an incomplete baseline care plan document. Review of the care plan revealed that no information was completed on the baseline care plan form, and the comprehensive care plan was not initiated until after the 48-hour window had passed. Interviews with facility staff revealed confusion regarding responsibility for initiating the baseline care plan. The DON stated that the admission nurse was responsible, while an LVN indicated that RNs should complete the care plan but was unsure who was responsible for the resident in question. The DON later clarified that either an RN or LVN could open the baseline care plan. Additionally, the resident's admission MDS was incomplete, with the BIMS section left blank. The facility's policy referenced the CMS guidelines for the care area assessment process.