Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a baseline care plan within 48 hours of admission for one resident. The clinical record review showed that the resident was admitted with a PICC line, was always incontinent of bowel and bladder, had multiple wounds, a colostomy, and was taking insulin. Despite these complex care needs, there was no evidence in the clinical record that a baseline care plan was created within the required timeframe following admission. Interviews with staff confirmed that the baseline care plan is typically developed by the admitting nurse and should include essential information such as diet, mobility, behaviors, catheters, and colostomy care. However, staff were uncertain about including the PICC line in the baseline care plan. The administrator acknowledged that no baseline care plan was available for the resident in question. Facility policy requires a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident.