Failure to Complete Baseline Care Plan Within 24 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 24 hours of admission for a resident who was admitted with multiple complex medical conditions, including unspecified encephalopathy, paroxysmal atrial fibrillation, an implantable cardiac defibrillator, essential hypertension, a history of transient ischemic attack, cerebral infarction without residual deficits, hemiplegia and hemiparesis affecting the right dominant side, dysphagia, and difficulty walking. The resident was a full code and required assistance from one person to ambulate with a walker. Upon review, the only care plan present was dated several days after admission and addressed only two care areas: risk for falls and risk of impaired nutritional status. Further review of the facility's Baseline Care Plan Policy revealed that a baseline plan of care should be developed within 24 hours of admission and must include specific elements such as initial goals for care, immediate ADL needs, initial orders, dietary orders, therapy plan, social services, and PASRR recommendations if applicable. An interview with the Regional Consultant confirmed that the baseline care plan was not developed within the required timeframe for this resident.