Failure to Develop Timely Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident, as required. The resident, an adult male with a history of left intertrochanteric femur fracture, metabolic encephalopathy, chronic kidney disease stage 4 with acute kidney injury now with end stage renal disease, and insulin-dependent diabetes mellitus, was admitted in the evening and discharged four days later. Despite these complex medical needs, the baseline care plan was not completed until ten days after admission, well after the resident had already been discharged. The resident's hospital records indicated insulin-dependent diabetes, but admission orders did not include physician orders for blood sugar checks or diabetic care. Nursing notes showed that blood glucose checks were performed only on the third and fourth days after admission, with elevated readings documented. Interviews with facility staff revealed that the admitting nurse was responsible for taking orders and contacting the physician but did not review the resident's diagnoses or the hospital discharge packet. The ADON stated that administration was not present during the weekend admission and was unaware of the events that led to the delay in care planning. The administrator indicated that he does not oversee the admission or care planning process, leaving it to the nursing department. The admitting nurse reported that after obtaining provider orders, the hospital packet was left in a basket for administrative review, but the baseline care plan was not created in a timely manner.