Failure to Develop Timely Baseline Care Plan Addressing Substance Use and Suicide History
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Specifically, the baseline care plan did not address the resident's history of substance use (heroin) and suicide attempts, despite this information being available in the hospital discharge paperwork and psychiatric consults. The resident was admitted with diagnoses including psychoactive substance induced disorder, depression, and anxiety, and had a documented history of opioid use disorder (on suboxone maintenance), prior inpatient psychiatric hospitalization, and previous suicide attempts or statements. Interviews with facility staff revealed that the social worker, who was responsible for completing the social service section of the baseline care plan, acknowledged that the resident's suicide attempt history and heroin use history should have been included. The Director of Nurses and MDS coordinator both confirmed that baseline care plans are expected to be completed within 48 hours of admission and should be personalized based on the resident's history. The omission was identified during a review of the resident's records and confirmed through staff interviews.