Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing the immediate needs of two residents within 48 hours of their admission. One resident was admitted with diagnoses including diabetes, heart failure, and end stage chronic kidney disease, and required dialysis, antidepressant, and diuretic medications. Despite the completion of the nursing admission assessment, there was no evidence that a baseline care plan was developed within the required timeframe. Staff interviews revealed that baseline care plans were typically completed within 72 hours, often during the interdisciplinary care conference, and sometimes delayed over weekends. Another resident was admitted with multiple sclerosis, polyneuropathy, depression, and pressure ulcers, requiring antidepressant medications, physical therapy, and daily wound care. Similarly, the nursing admission assessment was completed, but no baseline care plan was documented within 48 hours of admission. Staff interviews confirmed that the practice was to complete baseline care plans within 72 hours, not the required 48 hours, and that immediate care needs were not formally addressed in a timely manner for these residents.