Failure to Develop 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 newly admitted resident. Record review showed that the only item addressed in the baseline care plan was the resident's full code status, with no documentation of other essential care areas such as allergies, fall risk, skin conditions, bowel and bladder needs, pain management, or nutrition. The resident in question was admitted with significant medical needs, including a traumatic subdural hemorrhage and a cognitive communication deficit, and was discharged to an acute care hospital after 10 days. Interviews with facility staff, including the MDS nurse and the DON, confirmed that the baseline care plan was insufficient and did not meet professional standards for person-centered care. The MDS nurse stated that the care plan should have included comprehensive information to guide care, and the DON acknowledged that the document was lacking critical details such as medications, transfer status, and therapy needs. The facility's care planning policy did not address baseline care planning for new admissions.