Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required by facility policy. For one resident, who was admitted with muscle weakness and was cognitively intact, the baseline care plan did not address oral hygiene needs. The MDS coordinator confirmed that a baseline care plan for this resident was not developed, despite the facility's policy mandating a person-centered care plan be created within 48 hours of admission. For another resident, staff failed to implement the baseline care plan intervention for pressure injury treatment as ordered by the physician. The baseline care plan identified the resident as being at risk for skin breakdown and included an intervention to provide wound treatment as ordered. However, review of the electronic treatment administration record did not show evidence that the wound care was completed on a specified date, and there was no documentation of treatment refusal. Staff interviews confirmed that wound care should have been provided and documented according to the care plan.