Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident's electronic health record showed that only some components of the baseline care plan were completed over a period of days, with two essential components—General Information and Initial Goals and Health Conditions—remaining incomplete as of nearly two weeks after admission. Interviews revealed that the nurse responsible for admitting the resident did not complete the baseline care plan as required, and administrative staff were unaware of the 48-hour completion requirement. The facility's policy stated that an initial person-centered care plan should be developed within 48 hours of admission, but this was not followed in the case reviewed.