Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident, who had a wound and experienced forgetfulness and confusion, was observed at the nursing station wearing soiled clothing and reported needing assistance with dressing and hygiene. Documentation showed that the resident's needs for activities of daily living varied, requiring different levels of assistance, but no baseline care plan was in place to address these needs within the mandated period. Interviews with staff confirmed that a baseline care plan had not been completed for the resident, and at the time of the survey, the care plan in the electronic medical record was still blank. The facility's policy required that a baseline care plan be developed and implemented within 48 hours of admission, including essential healthcare information to properly care for the resident. The lack of a timely baseline care plan had the potential to affect all new admissions.