Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop resident-centered baseline care plans within 48 hours of admission for two residents. For one resident with a history of cerebral infarction, aphasia, gait abnormalities, and dysphagia, there was no communication problem care plan initiated upon admission or up to the time of the survey. Clinical records and interviews with the ADON and MDS Coordinator confirmed that the resident's MDS indicated significant communication deficits, yet no baseline care plan addressing these needs was created within the required timeframe. For another resident admitted with a primary diagnosis of malignant neoplasm of the breast, there was no baseline activity care plan developed, and no activity care plan was present at all. The resident's physician order allowed participation in activities as tolerated, but the activity director confirmed that the resident had not been assessed for activities and no baseline activity care plan was created within 48 hours of admission, as required by facility policy. These findings were verified through record review and staff interviews.