Failure to Develop Timely, Resident-Specific Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to develop baseline care plans containing resident-specific goals and interventions with the minimum healthcare information necessary to properly care for residents within 48 hours of admission for four out of six sampled residents. For one resident with malnutrition, adult failure to thrive, dementia, and receiving hospice services, there was no documentation of a baseline care plan for hospice and nutrition within the required timeframe. Another resident with weakness and Multiple Sclerosis (MS), who was cognitively intact, did not have a baseline care plan to instruct staff on immediate care needs related to MS. Similarly, a second resident with MS and weakness, also cognitively intact, lacked a baseline care plan addressing MS-related needs. Staff confirmed that baseline care plans had not been completed for these residents. A fourth resident admitted with surgical aftercare following a hip fracture, cirrhosis, and ascites, and who was alert and able to communicate needs, did not have a baseline care plan reflecting the need for weekly paracentesis and daily diuretics, despite significant weight loss and relevant physician orders. The nutrition care plan for this resident was not individualized and did not address the specific interventions required for their condition. Staff interviews confirmed the omission of these critical care needs from the care plan.