Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for five out of ten sampled residents. Clinical record reviews revealed that for each of these residents, the required baseline care plan, which should include problems, goals, and interventions necessary to provide minimum healthcare information, was either not created or not implemented within the mandated timeframe. In several cases, the care plans were delayed by several days, with some not being completed until four days after admission. These findings were confirmed through interviews with facility staff, including the Regional Marketing Advisor, Administrator, Director of Nursing, and Market Clinical Advisor, who acknowledged the delays and lack of timely documentation. The residents involved were admitted for skilled care, and their clinical records lacked evidence of timely baseline care planning. The absence of these care plans meant that essential instructions for providing appropriate care were not available to staff within the first 48 hours of the residents' stay. The deficiency was consistently identified across multiple residents, as confirmed by both record review and staff interviews, indicating a pattern of non-compliance with regulatory requirements for timely care planning upon admission.