Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline plan of care within 48 hours of admission for one resident. The facility's policy required a baseline care plan to be created within 48 hours to address the resident's immediate needs. The resident in question was admitted with multiple diagnoses, including diabetes, vascular dementia, chronic kidney disease, and dysphagia. Upon admission, the resident was assessed by nursing as being at risk for elopement, exhibiting behaviors such as exit seeking, wandering, and disorientation. However, the section of the Elopement Risk Evaluation intended for documenting interventions and care planning was left blank. Further review of the resident's care plan report and medical record showed that no baseline plan of care or interventions were documented prior to the resident's elopement from the facility. The Director of Nursing confirmed that a baseline plan of care, including an elopement plan, should have been developed within 48 hours of admission but was not completed in this case.