Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to complete a comprehensive baseline care plan within 48 hours of admission for a resident with multiple medical conditions, including hypertension, history of falls, confusion, osteoarthritis, frequent urinary tract infections, back pain, an indwelling Foley catheter, and oxygen use. Review of the resident's electronic medical records and baseline care plan revealed that only pain and ineffective peripheral tissue perfusion were addressed, with no focus, goals, or interventions documented for Foley catheter use, ADL status, transfer status, cognitive status, fall status, or oxygen use. Staff interviews confirmed that the baseline care plan was incomplete and did not include all necessary information required for proper care, contrary to facility policy.