Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop baseline care plans (BCPs) within 48 hours of admission for six out of ten residents reviewed for new admissions. The BCPs were either incomplete or missing, lacking essential elements such as resident-specific goals, physician orders, dietary orders, treatment plans, and social service needs. This was contrary to the facility's own policy, which required a BCP to be developed within 48 hours of admission to include the minimum healthcare information necessary for resident care. For several residents, the BCPs that were completed did not include required information. For example, one resident admitted with palliative care needs, Alzheimer's disease, severe malnutrition, and hospice services had a BCP that omitted resident-specific goals and interventions for dietary, social services, and hospice care. Another resident with sepsis and a PICC line for antibiotic therapy had a BCP that lacked goals and interventions for dietary orders, physician orders, social services, and PICC line care. Additional residents with complex medical needs, such as stroke, surgical aftercare, and amputation, either had incomplete BCPs or no BCP documentation at all. Interviews with facility staff revealed that recent staffing changes contributed to gaps in the completion of BCPs. Staff acknowledged that the process for developing BCPs was not being followed as required, and some BCPs were simply missed. The facility's process was described as including a review of the BCP within 24 hours of admission, but this was not consistently implemented for the residents reviewed.