Failure to Initiate 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 its own policy. The resident was admitted with a right tibia fracture status post open reduction and internal fixation surgery, as well as a diagnosis of major depressive disorder. Despite being cognitively intact and having specific medical needs, including the use of a leg brace and medication for depression, no baseline care plan was found in the electronic medical record. The absence of this care plan meant that person-centered interventions addressing the resident's depression, antipsychotic medication use, and post-surgical care were not documented or initiated as required. Interviews with facility staff, including the social worker, RN, and DON, revealed confusion and lack of clarity regarding who was responsible for initiating and entering the baseline care plan. The social worker confirmed meeting with the resident on the day of admission to review paperwork and discharge planning but did not discuss care planning. The RN and DON both expressed uncertainty about their roles in the baseline care plan process, and the DON was unable to locate the required documentation. The facility did not follow its own policy, which mandates the development and implementation of a baseline care plan within 48 hours of admission.