Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required. For one resident with end-stage renal disease and diabetes mellitus, the baseline care plan addressed dialysis needs but did not include interventions for incontinence, skin integrity concerns, mobility limitations, or fall prevention, despite documentation of these issues in the clinical record. Staff interviews confirmed that the baseline care plan lacked the minimum healthcare information necessary to address the resident's immediate health and safety needs upon admission. For another resident with paraplegia, assessments identified a high risk for falls and a need for two staff to assist with bed mobility and hygiene. However, the baseline care plan did not document interventions to mitigate fall risk or include therapy recommendations for safe resident handling. Interviews with therapy and nursing leadership confirmed that the care plan was not updated to reflect these critical needs, and no evidence was provided to show that the required information was incorporated into the resident's baseline plan of care.