Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for seven out of seventeen residents reviewed. The BCPs were missing required components such as resident-specific goals, physician orders, dietary orders, therapy services, social service needs, and documentation of the Preadmission Screening and Resident Review (PASRR). Additionally, the facility did not provide a written summary of the BCP to the residents or their representatives, nor did they document the provision of this summary in the medical record as required by facility policy. Specific examples included residents with complex medical histories such as cellulitis, diabetes, depression, bipolar disorder, PTSD, heart complications, tracheostomy care, pressure ulcers, end-stage renal disease, dementia, and stroke. For these residents, the medical records and care plans reviewed showed that the required BCP components were not developed or documented within the mandated 48-hour timeframe. In some cases, residents reported not receiving a written care plan or a review of their medications upon admission, which led to confusion and unanswered questions about their care. Interviews with staff revealed a lack of awareness regarding the requirements for BCP development within 48 hours. Staff members stated that initial care plans focused only on basic activities of daily living and did not include other mandated elements such as initial goals, physician orders, therapy, or social services information. The Assistant Regional Director for Clinical Services confirmed that BCPs had not been developed for the identified residents within the required timeframe.