Failure to Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans that included necessary instructions to provide effective and person-centered care for all ten residents reviewed. Clinical record reviews and staff interviews revealed that, for each resident, the baseline care plan was either incomplete or contained errors within the required timeframe following admission. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables to address residents' physical, psychosocial, and functional needs, but this was not achieved for any of the residents in the sample. The residents affected had a range of complex medical conditions, including Alzheimer's disease, bipolar disorder, dementia, diabetes, spina bifida, bladder cancer, endocarditis, atrial fibrillation, encephalopathy, chronic obstructive pulmonary disease (COPD), wedge fracture, prostate cancer, heart failure, and throat cancer. Despite these significant diagnoses, the baseline care plans were not completed within the required period after admission, with some remaining incomplete for up to 21 days. The Nursing Home Administrator confirmed the failure to develop and implement appropriate baseline care plans for all residents reviewed.