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 48 hours of admission for a newly admitted resident who subsequently developed a Stage II pressure ulcer. The resident, who had an intact mental status and multiple complex medical conditions including infection due to a knee prosthesis, Type II Diabetes Mellitus, and Chronic Kidney Disease Stage 3, was admitted with specific physician orders such as a diabetic diet, non-weight-bearing status, wound vac, and intravenous antibiotics. Assessments documented that the resident was at risk for pressure ulcers, required moderate to maximum assistance for mobility, and had significant skin issues upon admission, including redness and maceration on the buttocks. Despite these findings, the resident's care plan did not reflect critical information such as the presence of a full-length leg cast, wound vac, urinary catheter, intravenous antibiotics, transfer and weight-bearing status, level of assistance needed for activities of daily living, risk for pressure injuries, pain management, or necessary interventions to prevent pressure ulcers. There was no documentation that a baseline care plan was completed within the required 48-hour timeframe after admission. Interviews with facility staff revealed that the DON, who was responsible for completing baseline care plans, was not present during the resident's initial days in the facility and no other nurses were trained to complete this task. As a result, staff relied on verbal reports to communicate care needs, and the administrator and DON were unaware that the resident had developed a pressure ulcer during her stay. The facility's policy required a baseline care plan to be developed upon admission and provided to the resident and their representative, but this was not followed in this case.