Failure to Develop Timely and Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by policy. The resident, who had intact cognition, was admitted with multiple diagnoses including anxiety, depression, contractures, joint pain, and osteoarthritis, and was prescribed several psychotropic and opioid medications. Documentation showed that the resident regularly received medication for chronic pain and anxiety, and her care plan was not initiated until several days after admission. The baseline care plan that was eventually created did not address the resident's chronic pain or psychotropic medication use, and it lacked a date and time of completion. Further review revealed that the baseline care plan was missing a signature and confirmation from the resident or her family, as required by facility policy. Staff interviews confirmed that the expected process was not followed, and progress notes did not document any confirmation of the care plan. The facility's policy required a baseline plan of care to be developed within 48 hours of admission to address immediate health and safety needs, but this was not completed for the resident in question.