Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident within 48 hours of admission, as required by facility policy. Medical record review showed that the resident was admitted with diagnoses including intracranial hemorrhage, respiratory failure, and COPD, and was assessed as severely cognitively impaired, dependent for all care, and at risk for pressure ulcers. Despite these significant care needs, there was no baseline care plan developed or implemented for the resident. This was confirmed during staff interview with the Regional Registered Nurse, who verified the absence of a baseline care plan upon admission. The facility's policy states that a baseline care plan must be developed within 48 hours to provide effective and person-centered care.