Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop a Baseline Care Plan for a resident who was admitted with diagnoses of myocardial infarction and major depression. The resident's electronic medical record did not contain a Baseline Care Plan, despite facility policy requiring an initial person-centered care plan to be completed within 48 hours of admission. The omission was confirmed through record review and an interview with administrative staff, who stated that a baseline care plan assessment is expected upon admission. The lack of a Baseline Care Plan was identified during a review of the resident's records and was not in accordance with the facility's stated procedures for ensuring continuity of care and communication among staff.