Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of its residents within the required timeframe following admission. Specifically, a resident admitted with diagnoses including cerebral infarction, dysphagia, and liver cirrhosis did not have a baseline care plan created within 48 hours of admission, as required by facility policy. The resident's Minimum Data Assessment indicated a need for moderate assistance with oral hygiene, toileting hygiene, and personal hygiene, and the resident was able to express ideas and understand others. Interviews with facility staff, including the Social Service Director, MDS Nurse, and Director of Nursing, confirmed that the interdisciplinary team did not create the required baseline care plan for this resident. The facility's policy states that an interim plan of care should be developed within 48 hours of admission to address the resident's initial needs, using information from various sources such as referring facilities, physician orders, and assessments. The absence of this plan was acknowledged by staff during the survey.