Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. For one resident with Alzheimer's disease, dementia, aortic stenosis, and osteoporosis, the electronic baseline care plan was completed but lacked signatures from the resident, the resident's representative, and the staff who developed the plan. The document was not properly signed or made available to the nursing staff, and the process for obtaining signatures was inconsistently followed. Another resident with a principal diagnosis of COPD, emphysema, dementia, and diabetes mellitus did not have their baseline care plan updated to address the principal diagnosis or the identified risks for hypoglycemia and hyperglycemia. The care plan was a revision of a previous stay's plan and did not include goals or interventions for the current admission's primary health concerns. Additionally, there was no documentation that the resident or their representative had been informed or included in the care planning process. A third resident with multiple diagnoses, including cerebral atherosclerosis, major depression, diabetes, and dysphagia, had an incomplete and undated baseline care plan in the electronic record, and the signed paper copy was not scanned into the electronic health record. As a result, the baseline care plan was not accessible to nursing staff and could not be updated to reflect changing needs. The facility's process for managing baseline care plans was inconsistent, leading to incomplete documentation and lack of communication among staff regarding residents' immediate care needs.