Failure to Develop and Communicate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for a resident. Specifically, for a resident admitted with a right humerus fracture and scalp laceration, the baseline care plan did not address urinary incontinence or incontinence care, despite the resident being assessed with these needs upon admission. Additionally, the care plan included a focus on pain management but did not document what the resident considered an acceptable level of pain. Further, there was no evidence in the clinical record or progress notes that the resident or their representative was provided with a summary of the baseline care plan within 48 hours of admission. This summary should have included initial goals, medications, dietary instructions, and services or treatments to be administered. Staff interviews confirmed these omissions, and facility policy requires that such information be documented and communicated to the resident and their representative.