Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for a recently admitted resident who had undergone a right tibia fracture repair and was non-weight bearing on her right leg. The resident required transfers using a full body mechanical lift, as indicated in her care plan and admission notes. However, the baseline care plan was not completed until several days after admission, and key interventions regarding her non-weight bearing status and transfer method were not added until seven days post-admission. On the evening following her admission, the resident reported to her daughter that a staff member was rough and rushed during a transfer to bed, which was performed using a slide board instead of the required mechanical lift. Although the resident was not injured, she experienced pain during the transfer and expressed a preference not to be cared for by the involved staff member. Staff interviews revealed that care sheets, which are updated daily, were used to guide care in the absence of a completed baseline care plan, but the official care plan outlining specific needs was not available to staff within the required timeframe. The facility did not have a policy specifically addressing baseline care plans and referenced federal requirements for developing and implementing such plans within 48 hours of admission. The DON confirmed that the baseline care plan was not completed as expected, and the responsible RN acknowledged that the care plan was not finalized at the time it was offered to the resident and her representative. This lapse resulted in staff relying on daily care sheets rather than a comprehensive, person-centered baseline care plan to guide immediate care needs.