Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered baseline care plan to address a resident's medical, nursing, mental, and psychosocial needs within 48 hours of admission. Review of the resident's medical record showed that, despite facility protocols requiring completion and filing of a baseline care plan within 48 hours, no such care plan was present for the resident. The resident was admitted with a psychiatric history, and staff were not aware of a recent diagnosis of suicidal ideations at the time of admission. Interviews with facility staff revealed that the admitting nurse was responsible for completing the baseline care plan upon admission, with oversight from the DON or ADON. The ADON stated that the baseline care plan template was loaded into the electronic health record at admission, but the admitting nurse did not complete it. The DON, who was on vacation during the admission, acknowledged that the baseline care plan was missed and was unaware of the resident's recent suicidal ideations. The administrator confirmed that the expectation was for the admitting nurse to complete the care plan and for the DON or ADON to follow up on any missing documentation.