Failure to Develop Baseline Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted and later re-admitted with multiple diagnoses, including cognitive communication deficit, pressure ulcer of the sacrum, laceration of the right foot with a foreign body, and unspecified dementia. The resident's admission MDS assessment indicated a BIMS score of 6, reflecting severe cognitive impairment. Despite these significant health concerns, there was no evidence that a baseline care plan was created to address the resident's impaired cognition. Interviews and record reviews confirmed that the facility's policy requires a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, including instructions for person-centered care. The DON acknowledged that impaired cognition and dementia are always risk factors for abuse and should be included in care planning to ensure staff awareness and appropriate care. However, the absence of a baseline care plan meant that staff did not have documented guidance to address the resident's cognitive impairment upon admission.