Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
Facility staff failed to develop and implement a baseline care plan for one resident within 48 hours of admission, as required. The clinical record review revealed that the resident, who had diagnoses including Alzheimer's disease, HIV, anxiety disorder, dementia, and malnutrition, did not have an admission assessment completed. The most recent MDS was a discharge assessment, and the comprehensive care plan lacked interventions for activities of daily living (ADL) such as bed mobility, dressing, eating, and transfers. During staff interviews, the MDS coordinator confirmed that the admission assessment and baseline care plan for ADL care were missing for this resident. This information was presented to the director of nursing and the administrator, with no further information provided before the exit conference. The deficiency was identified through clinical record review and staff interviews, which confirmed the absence of required documentation and care planning for the resident's immediate needs following admission.