Failure to Develop and Provide 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 facility policy. Review of the resident's electronic medical record showed no baseline care plan was present under the designated care plan section. The resident was admitted with significant medical conditions, including nontraumatic cerebral hemorrhage with right-sided hemiplegia and hemiparesis, dysphagia, urinary tract infection, and gastrostomy. The facility's policy states that a baseline care plan must be developed within 48 hours of admission and must include the minimum healthcare information necessary to properly care for the resident, as well as a written summary provided to the resident or their representative in an understandable language. Interviews with facility staff and the resident's family confirmed that neither a baseline care plan was created nor was a copy provided to the resident or their representative within the required timeframe. The LPN Unit Manager stated that she had never provided a baseline care plan to residents or families within 48 hours of admission, and the Director of Nursing was unable to locate a copy of the baseline care plan for the resident in question. The family also reported not receiving any documentation outlining the facility's concerns or care areas to be addressed.