Failure to Develop and Communicate Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan or comprehensive care plan with necessary information within 48 hours of admission for two residents. For one resident, the facility used a prior baseline care plan upon readmission and did not update signatures or create a new baseline care plan as required by facility policy. This resident had multiple medical diagnoses, including pneumonia, acute respiratory failure, depression, cognitive communication deficit, and anemia, and had new physician orders upon readmission that were not reflected in an updated baseline care plan. For the other resident, there was no evidence that a summary of the baseline care plan was provided to the resident or their representative. Interviews with facility staff revealed confusion and lack of adherence to policy regarding the creation and updating of baseline care plans, especially in cases of readmission. The admitting nurse and RN on duty were responsible for updating and completing baseline care plans, while the DON was responsible for monitoring signatures. Staff acknowledged that a new baseline care plan should have been started for readmitted residents, and that the failure to do so was not in line with facility policy. There was also a lack of documentation regarding the provision of baseline care plan summaries to residents or their representatives.