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 two residents with complex medical needs. For one resident admitted with acute respiratory failure, a Stage IV pressure ulcer, larynx cancer with a tracheostomy, and dysphagia with a gastrostomy tube, there was no documentation of baseline or comprehensive care plans addressing tracheostomy care, indwelling catheter, gastrostomy care, pressure ulcer treatment, or enhanced barrier precautions within the required timeframe. Similarly, another resident admitted with rectal and vaginal prolapse, a rectal wound, schizoaffective disorder, and a history of falls did not have baseline or comprehensive care plans developed or implemented to address antipsychotic medication use, fall risk, pain management, or wound care within 48 hours of admission. Interviews with nursing staff revealed confusion regarding responsibility for creating baseline care plans. The admitting nurse and Unit Manager were identified as responsible parties, but the admitting nurse reported never having completed a baseline care plan. The Assistant Director of Nurses and Director of Nurses confirmed the facility's expectation that the admitting nurse initiates the baseline care plan, with the Unit Manager verifying completion the following day. Despite these expectations, the required documentation was not present in the medical records for the two residents prior to the survey date.