Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The facility's policy, last revised in May 2024, requires that every resident have an interdisciplinary baseline care plan initiated within 48 hours of admission. However, record review and staff interviews revealed that for a resident admitted with vascular dementia, depression, and metabolic encephalopathy, there was no documented evidence of a baseline care plan in the medical record. The resident's Minimum Data Set assessment indicated severe cognitive impairment, but the resident was usually able to understand and be understood by others. Despite these needs, the baseline care plan was not located, as confirmed by the Regional Nursing Coordinator and the DON, who acknowledged the requirement but could not explain the omission. This failure was cited under 10 NYCRR 415.11.