Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans for several residents within 48 hours of admission, as required by policy. Specifically, two residents admitted with significant medical conditions did not have baseline care plans that addressed their mobility abilities. One resident, admitted with diagnoses including urinary tract infection, hypoxemia, anxiety, and heart failure, experienced a fall resulting in multiple fractures and bruising. The medical record review showed that the baseline care plan for this resident was not completed, and staff interviews confirmed that the care plan was overlooked. Another resident, admitted for hospice respite with diagnoses such as malignant neoplasm of the pancreas, neoplasm-related pain, protein-calorie malnutrition, and elevated blood pressure, also did not have a completed baseline care plan. This resident was found on the bathroom floor with a laceration above the eyebrow after attempting to use the restroom with only partial assistance. The admission MDS indicated the need for moderate assistance with toilet transfers, but the baseline care plan was not completed to reflect these needs. Staff interviews revealed that the resident required active assistance during toileting and should not have been left alone, but this was not documented in a care plan. Additional residents were also found to have incomplete or missing baseline care plans upon review. One resident with a history of stroke, hemiplegia, and moderately impaired cognition had documentation of an initial care plan conference, but the baseline care plan was not fully completed. Another resident with multiple chronic conditions, including congestive heart failure and severe kidney disease, had an undated baseline care plan with blank sections for social services needs and goals. Staff interviews confirmed that the responsibility for completing baseline care plans was with the DON and ADON, but these were overlooked, and the importance of these plans in preventing falls and meeting residents' needs was acknowledged.