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 multiple residents, resulting in a lack of clear instructions for providing effective and person-centered care. For several residents, including those with complex medical histories such as diabetes, pressure ulcers, recent falls, and amputations, the baseline care plans did not address critical areas such as fall risk, diabetes management, skin care, activities of daily living (ADLs), and personal preferences. In some cases, the care plans were either missing entirely or lacked essential information needed for staff to provide appropriate care. One resident with a history of diabetes, pressure ulcers, and repeated falls was admitted without a baseline care plan addressing these conditions. Despite documentation from previous providers indicating the need for ongoing diabetes management and skin care, the facility did not include these in the resident's care plan. Communication breakdowns between medical providers and facility staff further contributed to the lack of clear care instructions, as decisions regarding medication management were not properly documented or shared. This resident subsequently experienced an emergency department visit for hyperglycemia and cellulitis, as well as an unwitnessed fall, while still lacking appropriate care plans for their conditions. Other residents admitted after hospitalizations for falls, amputations, or with multiple comorbidities also did not have timely or comprehensive baseline care plans. These omissions included failure to document ADL assistance, therapy goals, personal preferences, and care needs related to communication, behavioral symptoms, dental care, and psychotropic medication use. Interviews with facility leadership confirmed that baseline care plans were not developed or implemented within the required timeframe and did not contain the necessary information to guide staff in providing proper care.