Failure to Complete Timely and Comprehensive Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission, as required by policy. For one resident, the baseline care plan did not include a diagnosis of vascular dementia or any cognitive loss, despite the resident having a history of dementia and a moderately impaired cognition score on the MDS. The omission was noted in the resident's records and confirmed by interviews with family and staff, who acknowledged the importance of including such diagnoses in the care plan to ensure appropriate care. For another resident, the baseline care plan was not completed within the required 48-hour timeframe after admission. The care plan was completed two days late, and staff interviews revealed that the delay was due to the resident being admitted late and the admitting nurse not having time to complete the care plan. The responsibility for completing the care plan was supposed to be communicated to the oncoming nurse, but this did not occur in a timely manner. Facility policy states that a baseline plan of care must be developed within 48 hours of admission to address the resident's immediate health and safety needs. Staff interviews, including those with the ADON, DON, and Administrator, confirmed that the failure to complete and accurately document baseline care plans could result in staff not being aware of residents' specific needs. The records and interviews demonstrate that the facility did not adhere to its own policy and regulatory requirements regarding timely and comprehensive baseline care planning for new admissions.