Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing residents' immediate needs within 48 hours of admission for four residents. For one resident with diabetes, chronic respiratory failure, and COPD, no baseline care plan was initiated or completed within the required timeframe, despite the resident receiving insulin, antidepressants, and diuretics. The DON acknowledged that either she or the nurse should have completed the baseline care plan but could not explain the omission. Another resident with muscle weakness was admitted and later discharged home without a baseline care plan ever being included in the medical record. The DON confirmed this was overlooked, and the Administrator was unaware of the omission. A third resident admitted with a colostomy had a baseline care plan that did not reflect the presence of the colostomy, despite the admission MDS assessment indicating it. The DON stated this was an oversight. For a fourth resident with lack of coordination and dementia, no baseline care plan was found in the medical record, and the DON confirmed that the interdisciplinary team was responsible for its completion. The Administrator stated her expectation that baseline care plans be completed within 48 hours of admission and be accurate.