Failure to Timely Complete and Accurately Document Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included necessary instructions for effective and person-centered care within 48 hours of admission for two residents. For one resident, the baseline care plan was not completed within the required 48-hour timeframe, with the care plan being initiated four days after admission. Interviews with staff revealed confusion regarding responsibility for completing the baseline care plan, with LVNs believing RNs were responsible and the MDS Coordinator indicating that the initial admission assessment should trigger the baseline care plan. The delay in completing the care plan meant that important risks, such as fall risk, were not documented in a timely manner. For another resident, the baseline care plan failed to include the presence of a PICC line upon admission. Although the resident was admitted with a PICC line to the upper right arm, the baseline care plan incorrectly indicated that the resident did not have a PICC or central line. This omission was attributed to the admitting nurse not marking the correct section, and the MDS Coordinator did not revise the care plan to correct the error. Staff interviews confirmed that the presence of a PICC line should have been documented in the baseline care plan to ensure appropriate interventions were triggered. The facility's care plan policy required that care plans be initiated upon admission and developed within 48-72 hours, serving as a guide for care needs and preferences. However, the policy did not specifically address baseline care plans, and staff interviews indicated a lack of clarity regarding the process and responsibilities for completing these plans. The deficiencies identified could result in missed or inadequate care for residents, particularly those with complex medical needs or at risk for adverse events.