Failure to Complete 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 who was admitted with chronic obstructive pulmonary disease and was also receiving hospice services. Review of the resident's records showed that no baseline care plan was completed as required by facility policy. Interviews with nursing staff revealed confusion regarding responsibilities for care plan development, with some staff lacking access to the electronic health record and relying on co-workers or paper notes. At the time of review, there was no baseline care plan available in the resident's room or chart, and staff confirmed the absence of such documentation. The baseline care plan was only placed in the resident's closet after the deficiency was identified.