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. The resident, a male with chronic diastolic heart failure, atherosclerotic heart disease, paroxysmal atrial fibrillation, and difficulty walking, was admitted with multiple care needs, including assistance with activities of daily living, risk for pressure ulcers, and shortness of breath when lying flat. Despite these needs, review of the electronic medical record showed that a baseline care plan was not completed as required. Interviews with the Director of Nurses and an LVN confirmed that it was the responsibility of the admitting nurse to complete the baseline care plan using an admission checklist, and that the DON was to review and sign off on the plan. Both staff members acknowledged that the absence of a baseline care plan could result in residents not receiving appropriate care, such as proper transfers or hygiene assistance. The facility's policy required the baseline care plan to be developed within 48 hours, but this was not done for the resident in question.