Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, as required. Staff interviews revealed that one staff member did not review or look at the resident's baseline care plan, while another staff member, who oversees care planning, stated that baseline care plans are supposed to be completed within 48 hours and that nursing staff are responsible for initiating and updating them. Record review showed that the baseline care plan for the resident was not filled out and did not include essential information such as cognitive status, ADL status, bowel or bladder status, transfer status, respiratory status (including oxygen use), communication status, mobility device use, or type of diet. The resident had diagnoses of lung cancer, pain, and type II diabetes mellitus. The facility's policy requires that care plans be initiated upon admission and describe the services necessary to attain or maintain the resident's highest practicable well-being.