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. Record reviews showed that the resident, a female with multiple complex diagnoses including hypertensive heart disease, vascular dementia, epilepsy, breast cancer, Crohn's disease, and osteoporosis, did not have a baseline care plan initiated or documented in the electronic health record under any relevant tabs. No comprehensive MDS assessments or care plans were found for the resident within the required timeframe. Interviews with facility staff, including the DON, ADON, and ADM, confirmed that a baseline care plan had not been completed within 48 hours of the resident's admission. Staff acknowledged that the absence of a timely baseline care plan could negatively impact the care provided, as it is essential for identifying and addressing the immediate needs of newly admitted residents. The facility's own policy requires a baseline plan of care to be developed within 48 hours of admission, but this was not followed in this instance.