Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident. Specifically, a female resident admitted with diagnoses including pneumonia, chronic pulmonary disease, and emphysema, and who was on continuous oxygen, did not have a baseline care plan documented in her facility records. The Admission MDS assessment indicated no cognitive impairment. During an interview, the DON acknowledged that a baseline care plan should have been completed upon the resident's readmission and stated that the admitting nurse was responsible for this task. However, the DON was unable to explain why the care plan was not completed, noting she was new to her position and still acclimating. Facility policy requires a baseline plan of care to be developed within 48 hours of admission.