Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident who was admitted with multiple complex diagnoses, including cerebral infarction, interstitial pulmonary disease, and dementia. The resident was prescribed oxygen therapy as needed and had additional medical conditions such as diabetes and a history of stroke. Although the comprehensive care plan was initiated several days after admission, there was no evidence that a baseline care plan was completed or provided to guide staff in meeting the resident's immediate needs during the initial period following admission. Interviews with facility staff revealed that the admitting nurse did not initiate the baseline care plan, and there was confusion among staff regarding responsibility for this task. The LVN responsible for the admission was unaware of the requirement to initiate the baseline care plan, believing it was the responsibility of an RN. The ADON and DON acknowledged that the baseline care plan was overlooked and confirmed that their expectation was for all new admissions to have a baseline care plan completed within 48 hours. Facility policy also indicated the importance of timely completion and implementation of baseline care plans to ensure continuity of care and communication among staff.