Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission or readmission for one resident, as required by both regulation and the facility's own policy. Specifically, a review of the resident's medical record showed that no baseline care plan was created following the resident's readmission in March 2021. This was confirmed during interviews with both a licensed nurse and the MDS coordinator, who acknowledged that the baseline care plan was not completed as required. The facility's policy states that a baseline care plan must be developed within 48 hours of admission to provide effective, person-centered care and to guide staff in meeting the resident's needs. The resident involved had a complex medical history, including chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure, hypertensive heart disease with heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease. The absence of a baseline care plan meant that there were no documented instructions for staff to follow to address the resident's specific care needs immediately after admission. Both the licensed nurse and the MDS coordinator confirmed that this omission was contrary to facility policy and could negatively affect the resident's health and well-being.