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 resident who was admitted for a respite stay and had multiple complex medical diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. The resident was noted to be severely cognitively impaired for daily decision-making but was independent with mobility and transfers. Upon review, the baseline care plan for this resident was found to be blank and undated, and several sections of the clinical admission documentation, including care planning and special care, were also incomplete or left blank. Interviews with facility staff revealed confusion and lack of clarity regarding the process and responsibility for completing baseline care plans. Licensed vocational nurses involved in the admission assessment believed that the MDS Coordinator was responsible for generating the care plan, while the MDS Coordinator stated that the baseline care plan should be started on admission and completed within 72 hours, but acknowledged that the resident's care plan was incomplete. Other nursing staff were unaware of the requirements or their roles in the development of the baseline care plan, and the ADON was unsure of the required timeframe for completion. The facility's documentation policy required that all services provided, progress toward care plan goals, and changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. However, the lack of a completed baseline care plan and incomplete documentation in the resident's record indicated that these requirements were not met for this admission, resulting in a deficiency related to the timely development and implementation of a person-centered care plan.