Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to review healthcare practitioner orders and implement a baseline care plan addressing immediate needs such as physician orders, dietary needs, therapy services, social services, and PASRR recommendations. For a resident admitted with multiple diagnoses including a right femur fracture, history of falls, difficulty walking, muscle weakness, a stage 2 pressure injury, and atrial fibrillation, there was no documentation of a baseline care plan or comprehensive care plans addressing these needs within the required timeframe. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for completing baseline care plans. Nurses on the floor indicated that the Unit Manager was responsible, while the Nursing Supervisor also deferred responsibility to the Unit Manager. The Unit Manager acknowledged missing the completion of the baseline care plan for the resident, and the DON was unaware that the care plan had not been completed within 48 hours as required. Comprehensive care plans for the resident were not in place until five days after admission.