Failure to Complete and Implement 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. The baseline care plan did not identify the resident's code status, omitted active diagnoses contributing to admission, and failed to address risks associated with dementia, weakness, and the use of psychotropic medications. Additionally, the care plan incorrectly indicated no history of falls and lacked a completion date. Required signature sections for both the resident/representative and staff were left blank. Interviews with staff revealed uncertainty about the care planning process and how information from the baseline care plan was communicated to certified nursing assistants (CNAs). Some staff were unaware of how to access the baseline care plan, and one staff member stated that the only care information available was a sheet completed by the DON. The lack of a completed evaluation and missing staff signatures contributed to the incomplete baseline care plan.