Failure to Develop Baseline Care Plan for New Admission with Malnutrition
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one newly admitted resident diagnosed with severe protein calorie malnutrition. According to facility policy, a baseline care plan must be created within 48 hours to address the resident's immediate health and safety needs, including initial goals, physician orders, and dietary orders. Review of the clinical record for this resident showed no documented evidence of a baseline care plan addressing the resident's nutritional status and weight until several days after admission, when a comprehensive care plan was eventually developed. The absence of a baseline care plan was confirmed during an interview with the facility dietician, who acknowledged that no such plan was in place for the resident's nutrition. The deficiency was cited under 28 Pa Code 211.10(c) Resident care policies and 28 Pa Code 211.12(d)(5) Nursing services, as the facility did not follow its own policy or regulatory requirements for timely care planning upon admission.