Failure to Complete 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 a resident with significant care needs. The resident, who had moderate cognitive impairment and functional limitations due to left-sided weakness following a cerebral infarction, required assistance with activities of daily living such as dressing, grooming, bathing, and mobility. The resident's medical history included cerebral infarction, heart failure, hypertension, diabetes, muscle weakness, and unsteady gait. Despite these complex needs, the 48-hour baseline care plan was not completed in a timely manner and lacked critical information and specific interventions. Upon review, several sections of the baseline care plan were left blank, including communication, nutrition, psychotropic medication use, respiratory, skin, hospice, dialysis, smoking, and enhanced barrier precautions. The care plan did not address the resident's diagnosis of type 2 diabetes, nutritional needs, insulin administration, or provide instructions for monitoring blood sugars and signs of hyper- or hypoglycemia. Additionally, while the resident was identified as having visual impairment, the care plan only referenced this in relation to fall risk and did not include specific goals or interventions for the impairment itself. The director of nursing confirmed during an interview that the baseline care plan was not completed within the required 48-hour timeframe and acknowledged its importance in directing staff on the care needed. The lack of a completed and comprehensive baseline care plan resulted in inadequate direction for staff to address the resident's immediate and ongoing care needs upon admission.