Failure to Develop and Implement Timely and Comprehensive Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two out of three residents reviewed. For one resident with multiple complex diagnoses, including urinary tract infection, diabetes, depression, blindness, and traumatic brain injury, the baseline care plan was not completed until four days after admission, exceeding the required 48-hour timeframe. This delay was confirmed by record review and interview with the Director of Nursing, who acknowledged the care plan should have been completed within the specified period. For another resident with a history of cerebrovascular disease, Klebsiella pneumoniae infection, anemia, diabetes, hyperlipidemia, dementia with psychotic disturbance, blindness, hypertension, chronic kidney disease, and urinary tract infection, the baseline care plan developed did not address several critical conditions, including dementia with psychotic disturbance, Klebsiella pneumoniae, blindness, and sequelae of cerebrovascular disease. The Director of Nursing confirmed that these conditions should have been included in the baseline care plan and that it is her expectation for care plans to be both timely and comprehensive.