Failure to Initiate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and implement a baseline care plan within 48 hours of admission for three residents who required varying levels of assistance with activities of daily living (ADLs) and had complex medical conditions. For each of these residents, the electronic health record (EHR) did not show evidence that a baseline care plan was initiated within the required timeframe after admission. Instead, the baseline care plans were developed several days after admission, as indicated by the dates in the EHR. The residents involved had diagnoses including end stage renal disease, heart failure, hypertension, cirrhosis, diabetes mellitus, arthritis, depression, dependence on renal dialysis, chronic pain, acute on chronic systolic heart failure, atrial fibrillation, coronary artery disease, localized edema, prosthetic heart valve, coronary angioplasty implant and graft, fracture, and anxiety disorder. During an interview, a registered nurse manager confirmed that baseline care plans should be completed within 24 hours of admission and acknowledged that this was not done for the three residents in question. The facility's own care plan policy required the development of a baseline care plan upon admission, in accordance with federal and state regulations, to provide effective and person-centered care. The lack of timely baseline care plans meant that staff did not have documented guidance on how to care for these residents immediately after admission.