Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was newly admitted with a closed fracture of the upper and lower end of the left fibula and required daily Enoxaparin injections. Record review showed that as of June 25, 2025, the resident's medical record did not contain evidence of a baseline care plan that included the necessary instructions to provide minimum healthcare information for proper care in this area. This deficiency was confirmed during an interview with the Director of Nursing on the same day. The lack of a baseline care plan meant that essential instructions for the resident's care, particularly regarding the administration of anticoagulant therapy, were not documented or available to staff within the required timeframe after admission.