Incomplete Baseline Care Plan on Admission
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 complete baseline care plan within 48 hours of admission for one resident. Specifically, a female resident admitted for rehabilitation services following a left femur neck fracture, who also had a diagnosis of Cerebral Palsy, did not have this diagnosis included in her baseline care plan. Although the Cerebral Palsy diagnosis was identified in consultation with a psychiatrist, it was omitted from the initial care plan, as discovered during a record review. This omission occurred despite the requirement to address all relevant diagnoses in the baseline care plan to ensure continuity of care and communication among staff.