Failure to Develop Timely and Complete Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents, as required by policy. For each of these residents, the baseline care plans lacked essential elements such as resident-specific goals, physician orders, dietary orders, treatment plans, and social service needs. Specifically, one resident with a history of stroke, diabetes, and dementia required substantial assistance with activities of daily living and had moderately impaired cognition, but their baseline care plan did not address their specific care needs. Another resident admitted with lumbar osteomyelitis, sepsis, and urine retention, who had a PICC line and urinary catheter, did not have a baseline care plan that included focus areas, goals, or interventions related to their medical and social service needs. A third resident with respiratory failure, embolism, alcohol withdrawal, chronic pain, and edema, who required supervision for ADLs, also had a baseline care plan lacking in resident-specific goals and interventions. Interviews with facility staff confirmed that the baseline care plans were expected to be completed within 48 hours of admission and should include admission diagnoses, immediate goals, medications, therapy types, specialty orders, and discharge plans. However, the review of records and staff interviews revealed that these requirements were not met for the three residents reviewed, resulting in incomplete baseline care plans that did not address their immediate health and safety needs as outlined in facility policy.