Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when a resident transferred from the facility's Assisted Living to the Long Term Care (LTC) section and did not have a Baseline Care Plan implemented within 48 hours of admission, as required. The resident's clinical record showed an admission date to LTC, but the most recent Care Plan was not initiated until 12 days after admission. The earliest documented initiation date for any focus area within the Care Plan was 17 days post-admission. Staff interviews confirmed that no Baseline Care Plan was created upon the resident's transfer to LTC, and the previous Assisted Living Care Plan was not closed or replaced with a new one specific to LTC needs. The Director of Nursing (DON) and the MDS Coordinator both acknowledged the oversight, with the MDS Coordinator stating that she typically initiates key focus areas immediately but was unaware of why this did not occur for this resident. The facility's care planning policy, approved in December 2024, did not specify required timelines for completing baseline or comprehensive care plans. This lack of timely care planning upon admission resulted in the failure to meet the resident's immediate needs as required by regulation.