Failure to Complete and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, as required by policy. For one resident, the baseline care plan used upon readmission was not updated, and there was no evidence of updated signatures after the readmission. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and required specific treatments such as anticoagulant monitoring, anticonvulsant and antidepressant medications, and CPAP at night. The facility did not initiate a new baseline care plan or complete all new admission paperwork as required for a readmission, and the care plan was not updated to reflect the resident's current needs and orders. For another resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion regarding responsibilities for updating and signing baseline care plans, as well as a lack of clarity about the process for residents who are readmitted. The facility's policy requires that baseline care plans be developed and implemented within 48 hours of admission and that summaries be provided to residents or their representatives, but these steps were not completed for the two residents reviewed.