Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, as required by facility policy. Record review showed that the resident, a male with diagnoses including bipolar disorder and epilepsy, was admitted without a baseline care plan, comprehensive care plan, or MDS assessment documented in the electronic medical record. Interviews with staff revealed confusion and lack of knowledge regarding responsibility for completing baseline care plans, with the MDS Coordinator, floor nurses, ADON, and DON each providing differing accounts of who was responsible. Admission checklists used by floor nurses did not consistently include the baseline care plan requirement, and staff were unaware of the required timeframe for completion. The deficiency was further evidenced by staff interviews indicating that the process for developing baseline care plans was not clearly assigned or understood. The MDS Coordinator had no prior experience and was unaware of the 48-hour requirement, while the ADON and floor nurses were not informed of their roles in the process. The administrator and DON also provided inconsistent information about who was responsible for ensuring baseline care plans were completed. Facility policy clearly stated that a baseline plan of care must be developed within 48 hours of admission to meet residents' immediate needs, but this was not followed for the resident in question.