Failure to Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and provide a baseline care plan within 48 hours of admission for one resident. Specifically, a resident with multiple medical diagnoses, including laceration of the esophagus, history of anaphylaxis, gastrostomy status, hypertension, depression, anxiety, and anemia, was admitted to the facility. Documentation showed that the resident was cognitively intact and dependent on staff for all activities of daily living (ADLs). Despite facility policy requiring the baseline care plan to be developed and provided to the resident or their representative within 48 hours of admission, the care plan was not given to the resident until 23 days after admission. During an interview, the resident confirmed that no staff had discussed the care plan, provided a copy, or invited her to a care plan meeting within the required timeframe. The facility's own records indicated that the baseline care plan was completed and provided to the resident and her Power of Attorney well after the 48-hour window. The Regional Nurse confirmed that the Social Service department is responsible for providing the baseline care plan within 48 hours, but acknowledged that this did not occur in this case.