Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to discuss and complete a baseline care plan (BCP) within 48 hours of admission for one resident. Upon interview, the resident reported not being included in care plan decision-making at the time of admission. Record review confirmed that no BCP was found in the electronic health record and there was no documentation that the BCP was discussed with the resident or their family within the required 48-hour timeframe. The Director of Nursing acknowledged that the care plan discussion and documentation were delayed by 13 days after admission and confirmed that no earlier documentation existed. Review of the facility's policy indicated that a BCP should be developed and verified by a supervising nurse within 48 hours of admission.