Failure to Develop 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. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, mood disorder, anxiety disorder, difficulty walking, cognitive communication deficit, left hip osteoarthritis, cognitive impairment, and a history of falls. Documentation showed the resident had impaired hearing, generalized weakness, a urinary tract infection, lactic acidosis, incontinence, a need for two-person assistance with transfers, and skin tears on both the left upper and right lower extremities. The resident was also identified as high risk for falls based on the Morse Fall Risk score. Interviews with facility staff revealed that the responsibility for completing baseline care plans had recently shifted from the MDS Director to the admitting nurse, but not all nurses understood the new process. The MDS Director and DON both confirmed that a baseline care plan had not been completed for the resident within the required timeframe. Despite requests, no baseline care plan was provided for the resident, and staff acknowledged the process change and the additional time required to complete the care plan. The facility's policy required a baseline care plan to be initiated within 24 hours and completed within 48 hours of admission, but this was not followed in this case.