Failure to Complete Baseline Care Plans for ADL Needs Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission to address the activities of daily living (ADL) needs for two residents. One resident reported being instructed by staff to ambulate without a walker or gait belt, despite not being cleared by therapy for such activity. The baseline care plan for this resident did not include necessary ADL care needs such as walking, toileting, transfers, bathing, or eating. Staff interviews confirmed that the resident should have used assistive devices per therapy evaluation, but this information was not communicated or documented in the baseline care plan. Another resident was found by a family member to be in bed, dressed in day clothes, soaked in urine, and unable to access a shower room. The baseline care plan for this resident also lacked documentation of ADL care needs, including walking, toileting, transfers, and bathing. Staff confirmed that the baseline care plans for both residents were incomplete and that the admitting nurse did not complete them at the time of admission.