Failure to Initiate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for a resident with multiple complex medical needs. According to facility policy, a baseline care plan should be created within 48 hours to address immediate care needs, including initial goals, physician and dietary orders, therapy services, social services, and PASRR recommendations. However, for a resident admitted with diagnoses such as status-post left below the knee amputation, peripheral vascular disease, urinary retention with an indwelling catheter, diabetes mellitus, depression, and on anticoagulation therapy, there was no documentation of baseline or comprehensive care plans addressing these needs within the required timeframe. The resident's hospital discharge summary identified immediate care needs including a new surgical wound, indwelling catheter, psychotropic medication use, diabetes management, and anticoagulation therapy. Despite these needs, the medical record showed that nursing did not initiate, develop, or implement the necessary care plans for these conditions until 12 days after admission. Interviews with nursing staff and management revealed a lack of awareness and clarity regarding responsibility for completing baseline care plans, resulting in the resident's immediate care needs not being formally addressed as required by facility policy.