Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted with multiple significant diagnoses, including chronic kidney failure, heart failure, hypertension, diabetes mellitus, bacterial infections, obesity, muscle weakness, and bradycardia. Review of the resident's admission record and Minimum Data Set (MDS) confirmed that the resident was cognitively intact and had complex medical needs. However, the electronic medical record showed that no baseline care plan was completed for this resident, despite facility policy requiring such a plan to be developed within 48 hours of admission. Interviews with facility staff, including the MDS nurse, LVN, director of staff development, and director of nursing, revealed inconsistencies in understanding and implementing the baseline care plan process. Staff acknowledged the importance of completing a baseline care plan upon admission to ensure all resident needs were met and to guide appropriate care. The facility's policy specified that the baseline care plan should include physician orders, dietary orders, therapy services, social services interventions, PASARR recommendations, and initial goals. The absence of a baseline care plan for this resident meant that care and services were not formally planned or communicated to staff as required by facility policy.