Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for one of two sampled residents within 48 hours of admission. Specifically, a resident with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder, schizophrenia, and impaired cognitive functioning was admitted and later readmitted, but the baseline care plan was not completed within the required timeframe. Additionally, the comprehensive care plan was not updated after the resident's readmission. This was confirmed through record review and staff interview, where a Licensed Vocational Nurse acknowledged the omission and stated that the baseline care plan had not been completed as of several days after readmission. The facility's own policy requires a baseline care plan to be developed within 48 hours to address immediate health and safety needs.