Failure to Develop and Communicate Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive baseline care plans within 48 hours of admission for three residents, as required by its own policy and federal regulations. For one resident with Alzheimer's disease, a femur fracture, and other complex conditions, the baseline care plan omitted necessary details such as interventions for psychotropic and anticoagulant medications, did not specify the required mechanical soft diet, and lacked complete discharge planning information. Additionally, there was no documentation that the resident or their representative received or reviewed the baseline care plan, and the social services director did not meet with the resident until three days post-admission, without reviewing the care plan during that meeting. Another resident, admitted after a coronary artery bypass graft and left toe amputation, had a baseline care plan that addressed the amputation but failed to include the surgical wound from the bypass procedure. This resident also reported not receiving or reviewing a copy of the baseline care plan, and there was no documentation of a signed acknowledgement form in the medical record. Similarly, a third resident with severe cognitive impairment and prescribed antipsychotic medication had a baseline care plan that did not specify the use of antipsychotic medication or include appropriate interventions, and there was no evidence that the responsible party received the care plan. Staff interviews revealed inconsistencies in the process for developing, reviewing, and obtaining signatures for baseline care plans. The admitting nurse was identified as responsible for these tasks, but documentation was lacking in all three cases. The facility's failure to provide timely, person-centered baseline care plans and to ensure residents or their representatives were informed contributed directly to the deficiency.