Failure to Complete 48-Hour Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to complete a 48-hour baseline care plan upon admission for one resident. The resident's admission Minimum Data Set (MDS) assessment indicated she was cognitively intact, experienced depression several days a week, and required assistance with hygiene while being independent with transfers. She had multiple diagnoses, including heart failure, diabetes, COPD, respiratory failure, and atrial fibrillation, and was at risk for pressure ulcers. She was prescribed insulin, an anticoagulant, and a diuretic. The baseline care plan documented that she required assistance with bathing, dressing, hygiene, mobility, and transfers, but did not specify the level of assistance or the number of staff required for these tasks. During interviews, a registered nurse stated that the care plan lacked sufficient detail to determine the resident's care requirements or staffing needs. The director of nursing confirmed that the baseline care plan was missing essential information and acknowledged that the resident had not yet been added to the care sheets used by nursing assistants for guidance on activities of daily living, transfers, diet, and precautions. The facility's policy requires a baseline plan of care to be developed within 48 hours of admission to address immediate needs, but this was not completed for the resident in question.