Failure to Complete Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to complete baseline care plans within 48 hours of admission for two residents. For one resident with diagnoses including schizoaffective disorder, bipolar disorder, hypothyroidism, chronic embolism and thrombosis, and anxiety, the baseline care plan was not signed as complete until several days after admission. This resident had severe cognitive impairment, was dependent for most activities of daily living, was always incontinent of bowel and bladder, and had multiple pressure ulcers, including a stage four ulcer and three unstageable ulcers. The delay in completing the baseline care plan was confirmed by a registered nurse during an interview. For another resident with diagnoses such as acute kidney failure, dementia, COPD, atrial fibrillation, hypertension, and hyperlipidemia, no baseline or initial care plan was present in the medical record at the time of review. This resident was cognitively intact but required assistance with several activities of daily living and was frequently incontinent of bladder. The absence of a baseline care plan for this resident's admission was confirmed by the Director of Nursing during an interview.