Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by facility policy. The policy specifies that a baseline care plan must be created within 48 hours to address the resident's immediate needs, including initial goals, physician and dietary orders, therapy, and social services. Review of the resident's electronic record showed no documentation of a baseline care plan following the resident's admission. Interviews with facility staff, including the Social Services Director, MDS Coordinator, Administrator, and Director of Nursing, revealed inconsistent understanding of the required timeframe, with some staff stating 72 hours instead of the policy-mandated 48 hours. The resident involved had multiple complex diagnoses, including vascular dementia, type II diabetes mellitus, major depressive disorder, Alzheimer's disease, cerebral atherosclerosis, and a history of mini stroke. The resident was admitted to the facility, and nursing staff documented the arrival, but no baseline care plan was completed or documented within the required timeframe. This omission resulted in the resident's immediate care needs not being formally addressed as outlined in the facility's policy.