Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a newly admitted resident. Observation revealed that the resident was experiencing swollen legs with sock indentations and reported discomfort, as well as a need for assistance with dressing, personal hygiene, and meal setup. The resident's medical history included congestive heart failure, diabetes mellitus Type 2, bipolar disorder, hypertension, obesity, and atrial fibrillation. Despite these complex needs, the baseline care plan was not completed within the required timeframe. Record review showed that the baseline care plan was initiated several days after admission and not completed until a week later. During an interview, the staff member responsible for care plans stated that the delay occurred because she was not present at the time of admission and no other staff initiated or completed the plan in her absence. Facility policy requires that a baseline care plan be developed within 48 hours of admission to ensure effective and person-centered care, but this was not followed in this instance.