Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was admitted with multiple diagnoses, including acute kidney failure, type 2 diabetes mellitus, hyperlipidemia, hypertension, peripheral vascular disease, gastro-esophageal reflux disease, and a history of pulmonary embolism. Despite these complex medical needs, there was no completed baseline care plan in the resident's electronic medical record, and the Admission MDS assessment did not identify a BIMS score. The resident and their representative confirmed that they had not received a copy of a baseline care plan. Interviews with facility staff revealed that the admitting nurse or charge nurse was responsible for initiating the baseline care plan upon admission. The DON stated that the nurse assigned to the resident's admission had recently given notice and had not been present since, which contributed to the failure to initiate the care plan. The DON acknowledged that, as a result, the resident was at risk for not receiving care that addressed their specific needs. Facility policy required that a baseline care plan be developed within 48 hours of admission, but this was not followed in this case.