Failure to Complete Baseline Care Plans Upon Admission or Re-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 ensure that baseline care plans were completed for two of nine sampled residents upon admission or re-admission. For one resident who was re-admitted following major orthopedic surgery, there was no documentation of a baseline care plan being completed at the time of re-admission, as confirmed by the Director of Nursing (DON) who was unable to locate the required documentation. Another resident, admitted with diagnoses including diabetes, hypertension, and gait and mobility abnormalities, also did not have a baseline care plan completed upon admission. The DON confirmed that this resident did not have a baseline care plan and stated that nurses were responsible for completing these plans at the time of admission.