Failure to Develop Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop baseline care plans that included instructions to provide effective and person-centered care for two newly admitted residents. For one resident with multiple complex diagnoses, including hypertension, osteoarthritis, acute kidney failure, renal dialysis, heart failure, dementia, and depression, there was no evidence of a baseline care plan being developed following admission. This resident was noted to have severely impaired cognitive skills, moderate hearing difficulty, and was dependent on staff for all activities of daily living. Interviews with facility staff, including the MDS nurse, Corporate MDS, and DON, confirmed that the baseline care plan was not completed as required, and staff were unable to provide a reason for this omission. Another resident admitted with rhabdomyolysis and moderate cognitive impairment also did not have a completed baseline care plan. Record review showed an attempt to start the care plan, but it was left blank. Interviews with the MDS Coordinator and DON confirmed that the baseline care plan was either incomplete or missing, which could result in direct care staff not having the necessary information to provide appropriate care. Facility policy required that a baseline care plan be developed within 48 hours of admission to address immediate needs, but this was not followed for these residents.