Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan is required to be created promptly upon admission to address the resident's immediate needs until a comprehensive care plan is completed. Record review showed that the resident, admitted with multiple complex diagnoses including adverse effects of methamphetamines, cannabis abuse with intoxication, suicidal ideations, history of suicidal behavior, PTSD, generalized anxiety disorder, bipolar disorder, and major depressive disorder, did not have a baseline care plan in place. During an interview, the Director of Nursing confirmed that a baseline care plan was not developed for this resident, despite policy requirements.