Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing the immediate care needs of two newly admitted residents within 48 hours of admission, as required by facility policy. For one resident with a history of traumatic brain injury, seizure disorder, multiple falls, acute urinary retention with an indwelling catheter, and cirrhosis, there was no documentation that baseline care plans were created to address acute urinary retention, infection control precautions, fall risk, or medication titration needs. Similarly, another resident admitted with chronic obstructive pulmonary disease, pneumonia, normal pressure hydrocephalus, dysphagia requiring a gastrostomy tube, and a pressure injury did not have baseline care plans developed to address pneumonia management, gastrostomy tube care, infection control, anticoagulation therapy, or pressure injury care within the required timeframe. Interviews with facility staff, including the Unit Manager, Assistant Director of Nurses (ADON), and Director of Nurses (DON), revealed a lack of awareness that the baseline care plans for these residents had not been completed. Staff indicated that the admitting nurse is responsible for initiating the baseline care plan, with management expected to review new admission charts the following day to ensure completion. Despite these expectations, the required baseline care plans were not documented or implemented for the two residents within 48 hours of admission.