Failure to Develop Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan (BCP) within 24 hours of admission for one resident, as required by state regulation. A review of the facility's policy indicated that BCPs were to be developed within 48 hours, which does not meet the 24-hour requirement. There was no evidence in the medical record that a BCP was created for the resident, and this was confirmed by the Director of Nursing during an interview. The resident involved had multiple complex medical conditions, including dementia with severe cognitive impairment, pressure-induced deep tissue injury, Refsum's disease, pain, acute kidney failure, a history of blood clots, atrial fibrillation, hypertension, depression, anxiety, urinary retention, and abnormal weight loss. The resident required significant assistance with activities of daily living, had a urinary catheter, was always incontinent of bowel, had a history of falls, required a mechanically altered diet, had multiple pressure ulcers, and was on several medications including an antidepressant, anticoagulant, antibiotic, and opioid. Despite these needs, no BCP was developed to address the resident's immediate health and safety needs within the required timeframe.