Failure to Develop Baseline Care Plan for Immediate Needs
Penalty
Summary
The facility failed to follow its policy and procedure for developing a baseline care plan to address a resident's immediate needs within 48 hours of admission. Specifically, for one resident with multiple complex diagnoses—including cerebral infarction, COPD, chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, dysphagia, and major depressive disorder—no baseline care plan was completed in the electronic chart. The resident was cognitively intact but totally dependent on staff for activities of daily living. The care plan also did not address the resident's risk for skin breakdown, despite the assessment indicating a mild risk due to immobility. During interviews, the DON confirmed that the baseline care plan should have been completed within 48 hours of admission and should have included individualized interventions for skin breakdown prevention. The facility's own policy requires a preliminary plan of care to be developed within 24 hours of admission to meet immediate needs. Review of the electronic chart with the DON confirmed the absence of the required baseline care plan for this resident.