Failure to Develop Baseline Care Plan for ADL Oral Care Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, specifically regarding activities of daily living (ADL) for oral care. The resident was admitted with multiple diagnoses, including stroke, dysphagia, heart failure, aphasia, and systemic lupus erythematosus. Interviews with facility staff confirmed that the baseline assessment and care plan, which should have been completed within 48 hours as per facility policy, were not developed in the required timeframe. Staff also indicated that without the care plan, essential ADL care such as oral care would not be performed, as they rely on the care plan for daily care instructions. Review of the clinical record showed that the dental care plan was not initiated until several days after admission.