Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a baseline care plan was documented within 48 hours of admission for one of four residents reviewed for baseline care plans. Specifically, a resident admitted with medical diagnoses including encephalopathy and aftercare following total joint replacement did not have a baseline care plan initiated or completed in the electronic medical record. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, including initial goals, physician and dietary orders, therapy, and social services. Interviews with the Resident Care Manager and the Director of Nursing confirmed that the baseline care plan was not completed as required by policy.