Failure to Develop and Implement Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several newly admitted residents, as required by facility policy. Specifically, the baseline care plans for five residents did not include necessary goals and interventions related to their individual healthcare needs. For example, one resident with alcohol abuse did not have corresponding goals and interventions documented, and another resident with multiple mental health diagnoses and a Level II PASRR also lacked timely care planning. Additionally, a resident with severe protein-calorie malnutrition did not have dietary orders and instructions included in the baseline care plan until nine days after admission. Further deficiencies were noted for residents with dementia and repeated falls, as well as those with recent orthopedic surgery and specific dietary allergies. In these cases, the baseline care plans failed to specify the type and level of assistance required for activities of daily living (ADLs) and did not address dietary needs or allergies. These findings were confirmed through record reviews and interviews with the Market Lead Clinical Specialist, who acknowledged the absence of required care plan elements for the affected residents.