Failure to Develop Baseline Care Plan Upon Admission
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop a baseline care plan for one resident within 48 hours of admission, as required. Record review showed that the resident was admitted with multiple complex diagnoses, including chronic obstructive pulmonary disease, hypertension, bipolar disorder, chronic kidney disease stage 3, atrial fibrillation, and several fractures. Despite these significant medical needs, there was no evidence in the medical record of a baseline care plan being created to address the resident's immediate needs. This was confirmed during an interview with the MDS nurse, who acknowledged that a baseline care plan had not been developed for the resident.