Failure to Develop and Implement Baseline Care Plans Addressing Individual Needs
Penalty
Summary
The facility failed to develop and implement baseline care plans that addressed the individual needs of three residents upon admission. For one resident admitted with diabetes, heart failure, and muscle weakness, the baseline care plan noted bowel incontinence but did not include interventions or goals to address this issue. Another resident admitted with diabetes and dysphagia did not have a baseline care plan developed at all following admission. A third resident, admitted with depression and diabetes, was documented by nursing staff and a social worker as having a language barrier that required family members to translate. However, there was no evidence that this communication barrier was addressed in the baseline care plan. The Director of Nursing confirmed that these care areas were not documented in the residents' baseline care plans.
Plan Of Correction
F 0655 Residents 10, 13, and 19 care plans were updated to accurately reflect the resident's initial plan of care and families were made aware. All the residents have the potential to be affected by the deficient practice. All other residents in the facility were audited to ensure that baseline care plans are initiated within 48 hours of admission. All the pertinent departments will be educated on the policies and policies relating to the proper initiation of baseline care plan and accurate reflection of the baseline plan of care. Audits will be completed by the DON/Designee once a week for at least 3 residents for 3 months to ensure that the care plans are done for all new admissions within 48 hours of admission. All findings will be reported and reviewed by the QAPI committee monthly. Date of Compliance: 08/26/2025