Failure to Complete 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 for one resident, as required by policy. The resident, a male admitted with multiple diagnoses including a displaced hip fracture, muscle weakness, cognitive communication deficit, hypertension, and emphysema, was found to have a baseline care plan initiated four days after admission, rather than within the mandated 48-hour window. The resident's admission MDS indicated he was cognitively intact at the time of admission. Interviews with facility staff revealed that the social worker was primarily responsible for opening and completing baseline care plans, with input from the DON and nurses. The social worker acknowledged being aware of the 48-hour requirement but stated she was on vacation during the period in question and completed the care plan upon her return. The administrator confirmed that the responsibility was shared but primarily assigned to the social worker due to the absence of an MDS nurse. Both the DON and administrator were unaware that the baseline care plan had not been completed within the required timeframe. Facility policy clearly stated that a baseline care plan must be developed within 48 hours to meet immediate resident needs.