Failure to Complete Timely and Accurate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three out of five residents reviewed for care planning. Specifically, one resident was admitted with a diagnosis of anxiety disorder and prescribed Quetiapine Fumarate, a psychotropic medication, but the baseline care plan did not indicate the presence of psychotropic therapy, despite physician orders and medication administration records confirming its use. Two other residents did not have baseline care plans completed at all upon admission, despite having significant medical conditions such as moderate cognitive impairment and chronic obstructive pulmonary disease. Interviews with facility staff revealed confusion and inconsistency regarding responsibility for completing baseline care plans, with both the MDS Coordinator and nursing staff indicating that nurses were responsible for this task. Staff also reported challenges with a new electronic records system, which contributed to difficulties in timely and accurate completion of care plans. The facility's policy requires baseline care plans to be developed within 48 hours of admission and to include essential healthcare information such as physician orders, but this was not consistently followed for the residents in question.