Failure to Develop and Implement Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident admitted for short-term rehabilitation following hospitalization for weakness related to COVID-19 infection and chemotherapy for cancer. The resident also had unstageable sacral wounds and a history of depression, anxiety, and pain. Upon review, it was found that no baseline care plan was created within 48 hours of admission, as required. The only documentation found was a one-page care plan initiated after the resident had already been discharged, which was subsequently canceled and contained only a single intervention related to skin integrity. Interviews with the DON and NHA confirmed that no baseline care plan was completed for the resident during their stay. The DON was unable to provide evidence of a completed care plan, and the NHA acknowledged the deficiency, clarifying that any access to the record after discharge was for review purposes only. The lack of a baseline care plan meant that essential care instructions and continuity of care were not established for the resident during their admission.