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 a resident with diagnoses including acute respiratory failure, tracheostomy status, malignant neoplasm of the lung and supraglottis, anxiety, and COPD. Medical record review showed that although the resident was cognitively intact and an admission assessment was completed, there was no evidence that a baseline care plan was developed or included as part of the assessment. This was confirmed during an interview with the interim DON, who verified that the baseline care plan had not been completed. Facility policy requires that a baseline care plan be developed within 48 hours of admission to provide effective and person-centered care, but this was not followed in this instance.