Failure to Complete 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 a newly admitted resident. The resident, an elderly female with a recent femur fracture, high blood pressure, atrial fibrillation, and muscle weakness, was admitted and assessed as cognitively intact. Despite facility policy requiring a baseline care plan to be completed within 48 hours to address immediate health and safety needs, the care plan was not initiated until after this timeframe had elapsed. Interviews with facility staff, including the Registered Nurse Coordinator (RNC), Director of Nursing (DON), and Administrator (ADMN), confirmed that the baseline care plan was not completed as required. Staff acknowledged the oversight and indicated that the charge nurse was responsible for initiating the care plan, with the DON responsible for monitoring completion. No specific reason for the failure was provided beyond staff oversight, and the deficiency was identified through record review and staff interviews.