Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for two residents. For one resident admitted with type two diabetes mellitus, heart disease, and a head injury, the baseline care plan documented in the electronic medical record noted incontinence and the presence of an indwelling catheter, but did not include any interventions, rendering the care plan incomplete. Staff interviews confirmed that while nursing staff were aware of the catheter and responsible for ensuring appropriate orders, they did not take responsibility for completing the care plan. For another resident admitted with a displaced intertrochanteric fracture, gait abnormalities, and generalized muscle weakness, the electronic medical record did not contain a baseline care plan addressing the resident's needs. This resident was cognitively intact and required substantial to maximal assistance with toileting, personal hygiene, and showering. Interviews with facility leadership confirmed the expectation that baseline care plans should be completed within 48 hours of admission, and that floor nurses were responsible for initiating these plans.