Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. For one resident admitted with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy, only the dietary care plan was initiated within the required timeframe, while the remainder of the care plan was not completed until several days later. The care conference for this resident occurred after admission, but there was no evidence of a baseline care plan being established within 48 hours as required. Another resident admitted with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, and heart failure, also did not have a complete baseline care plan within 48 hours. Only a nutrition/hydration risk care plan was initiated, with no other care plans documented. Additionally, the care conference summary for this resident lacked signatures from the resident, family, or representative, indicating incomplete involvement. Interviews with facility leadership confirmed that the care plans for both residents were not completed fully or in a timely manner, contrary to facility policy.