Failure to Develop Baseline Admission Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop a person-centered baseline admission care plan within 48 hours for two residents following their admission. For one resident, who had a history of hemiplegia, hemiparesis following a stroke, and a brief psychotic disorder, there was no baseline care plan documented in the medical record. The comprehensive care plan that was present addressed some care needs but was undated, and the Director of Nursing (DON) confirmed that a baseline care plan should have been in place to ensure the resident received appropriate care. For another resident, who had end stage renal disease, hypertension, atrial fibrillation, and coronary artery disease, there was also no baseline care plan found in the medical record. This resident was dependent on staff for activities of daily living (ADLs) and had intact cognition. Interviews with facility staff, including the MDS Coordinator, Assistant Director of Nursing (ADON), and the admitting nurse, revealed confusion and lack of clarity regarding responsibility and procedures for initiating and completing the baseline care plan within the required timeframe. The facility's policy required a baseline plan of care to be developed within 48 hours of admission to address immediate health and safety needs. However, staff interviews indicated inconsistent understanding of this process, with some staff unaware of their responsibilities or lacking training on baseline care plan development. As a result, the two residents did not have individualized baseline care plans in place to guide their care during the initial period following admission.