Failure to Complete 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 following an acute care hospital stay. The resident had multiple diagnoses, including COPD, diabetes mellitus II, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, and required assistance with personal care. Upon review, the clinical record lacked documentation of a nursing admission assessment, physical assessment, skin assessment, baseline care plan, and catheter assessment until the afternoon of the fourth day after admission. The DON confirmed that there was no documentation regarding the resident's admission in the clinical record, and the baseline care plan was not completed in a timely manner, contrary to the facility's policy requiring completion within 48 hours.