Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline Care Plan within 48 hours of admission for a resident who was admitted with multiple diagnoses, including anemia, atrial fibrillation, non-Alzheimer's dementia, and unsteadiness on feet, with a recent history of falls. Documentation showed that the resident required significant assistance for transfers, toileting, and mobility, as indicated by therapy and nursing communication forms. However, the initial Care Plan was not initiated until several days after admission and did not include essential information regarding the level of staff assistance and supervision needed for activities of daily living such as bed mobility, transfers, toileting, and personal hygiene. Interviews with facility staff revealed a lack of clarity and established process for initiating baseline Care Plans, particularly following recent staffing changes in the MDS Coordinator position. The facility's policy required that a baseline Care Plan be developed and implemented within 48 hours of admission, including all necessary healthcare information and a written summary provided to the resident or their representative. This policy was not followed in the case reviewed, resulting in the deficiency.