Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required by policy and CMS guidelines. Specifically, the baseline care plan was not provided to one resident or their representative, and for three other residents, the baseline care plans were either incomplete or not developed within the required timeframe. The documentation review showed missing signatures, incomplete sections, and lack of acknowledgment by residents or their representatives. For one male resident with multiple complex diagnoses, including respiratory failure, depression, PTSD, hypertension, heart failure, COPD, benign prostatic hyperplasia, and obstructive uropathy, there was no indication that the baseline care plan was provided to him or his representative before his death. Another male resident with diagnoses such as type 2 diabetes, sepsis, prostate neoplasm, atrial flutter, anxiety disorder, depression, and hypertension had a baseline care plan that was signed and acknowledged, but the process for other residents was not completed as required. A female resident with mood disorder, schizoaffective disorder, morbid obesity, diabetes, general anxiety, vascular dementia, and depression had a baseline care plan that lacked essential information, including fall risk precautions, dietary instructions, medication orders, therapy services, and a summary provided to her. Another female resident with a femur fracture, delirium, and hypertension had a baseline care plan missing dietary instructions, social services, therapy services, and a summary for her or her representative. Staff interviews confirmed that sections of the baseline care plans were not completed on time due to workload and oversight, and the DON acknowledged the responsibility for timely completion was not met.