Failure to Develop Baseline Care Plan for Nutrition Needs
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by facility policy. The resident was admitted with diagnoses including severe protein-calorie malnutrition, anorexia, depression, and muscle weakness. Despite the resident's significant nutritional needs and self-reported weight loss, there was no documented evidence in the clinical record that a baseline care plan addressing nutrition was created or put into place. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a baseline care plan related to the resident's nutrition diagnosis.