Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 48 hours of admission for a resident who was admitted with diagnoses including encounter for removal of internal fixation device and multiple myeloma. The baseline care plan was not completed until four days after admission, contrary to the facility's policy which requires completion within 48 hours. Documentation showed that the care plan was created on the second day after admission but not finalized until the fourth day. Interviews with staff revealed confusion and inconsistency regarding the required timeframe for completing the baseline care plan, with several interdisciplinary team members, including the Director of Social Work, Registered Dietitian, and Director of Rehab, stating they believed they had 72 hours to complete the plan. Additionally, many of these staff members did not work on weekends, resulting in delays when residents were admitted late in the week. The Director of Nursing and Administrator confirmed that the baseline care plan was often completed on the following Monday if the admission occurred late on a Friday, due to the absence of key staff over the weekend.