Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident with multiple complex medical conditions, including hepatic encephalopathy, severe sepsis with septic shock, alcoholic cirrhosis, type 2 diabetes, anemia in chronic kidney disease, opioid dependence, chronic pain syndrome, neuropathy, gout, obstructive sleep apnea, lumbar radiculopathy, and hypertension. The facility's policy required a baseline care plan to be created within 48 hours to address immediate care needs, but a review of the resident's medical record showed no documentation of such a plan or a comprehensive care plan addressing the resident's needs prior to the survey date. Interviews with facility staff, including the Unit Manager, Assistant Director of Nurses (ADON), and Director of Nurses (DON), revealed that the MDS Nurse was responsible for creating baseline care plans within the required timeframe. However, none of the interviewed staff were aware that the baseline care plan for this resident had not been completed, indicating a lapse in the facility's process for ensuring timely care planning upon admission.