Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for one resident, as required to ensure effective and person-centered care. The resident, a female with diagnoses including Chronic Obstructive Pulmonary Disease, dyspnea, and dependence on supplemental oxygen, was admitted with orders for respiratory medications and hospice care. Although a baseline care plan was initiated and added to her chart, it was never completed. The Minimum Data Set (MDS) nurse acknowledged that she should have completed the clinical portion of the care plan, while the rest of the Interdisciplinary Team (IDT) was responsible for the remaining sections. However, the care plan was overlooked by all responsible parties. Interviews with facility staff, including the MDS nurse, Director of Nursing (DON), Assistant Director of Nursing (ADON), and a medication aide, confirmed that the care plan was not completed due to oversight. Staff indicated that the resident was well-known to them and had been admitted multiple times, which may have contributed to the oversight. The facility's policy requires the IDT to develop care plans, but in this instance, the process was not followed, resulting in the absence of a completed baseline care plan for the resident.