Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required. For both residents, there was no documentation of a care plan that included current diagnoses, care levels, measurable objectives, or timetables to address their physical, psychosocial, and functional needs. This omission was identified through observation, interviews, and record reviews, which confirmed that no baseline care plans had been initiated since their respective admissions. One resident was a 58-year-old female with multiple complex medical conditions, including acute respiratory failure, schizophrenia, pressure ulcers, and severe cognitive impairment, who was totally dependent on staff for activities of daily living. Interviews with the resident's daughter revealed that no care plan meeting had occurred. The other resident was a 63-year-old male with diagnoses such as hypertension, dementia with behavioral disturbances, diabetes with neuropathy, and a stage 3 pressure ulcer, who also exhibited moderate cognitive impairment. Observations and interviews confirmed that neither resident had a baseline care plan in place. Staff interviews indicated a lack of awareness and accountability regarding the completion of care plans. The administrator and social worker were not aware of the missing care plans and attributed the issue to recent staff transitions, including an interim DON and a new MDS nurse who was out sick. The ADON stated that care planning was the responsibility of the MDS nurse (RN), and as an LVN, she did not assume this responsibility. The facility's policy required comprehensive care plans to be developed within a specific timeframe, but this was not followed for the two residents in question.