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 one resident, as required by policy. Specifically, the baseline care plan for a moderately cognitively impaired female resident with chronic obstructive pulmonary disease, heart failure, and continuous oxygen needs was not completed. Only the Social Services section of the care plan was initiated, and no further interdisciplinary input was documented. Interviews with nursing staff, including RNs and LVNs, revealed a lack of clarity and training regarding responsibility for completing the baseline care plan. Several staff members assumed that either the DON or the MDS nurse was responsible, while the DON stated that the admitting nurse should initiate the plan and that it did not have to be an RN. The Corporate MDS Nurse confirmed that the baseline care plan was missing and described the intended interdisciplinary process, which was not followed in this case. Review of facility policies indicated that a baseline care plan must be completed within 48 hours of admission, initiated by an RN, and should address immediate needs based on admission orders, including physician, dietary, therapy, and social services input. The lack of a completed baseline care plan for the resident meant that her immediate needs, such as oxygen therapy, Foley catheter care, and infection management, were not formally addressed in a person-centered, interdisciplinary manner as required.