Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident who had recently undergone left hip hemiarthroplasty following a femur fracture. Documentation review showed that the resident required varying levels of assistance with activities of daily living (ADLs), including being dependent for toileting hygiene, requiring maximum assistance for bathing, and moderate assistance for bed mobility and transfers. Despite these needs being documented in the resident's Minimum Data Set (MDS) and other records, the baseline care plan addressing these needs was not created until more than 48 hours after admission, contrary to the facility's policy and procedure. Interviews with facility staff confirmed that the baseline care plan was delayed, and as a result, the care team may not have been fully informed of the resident's specific needs for supervision, behavioral interventions, and assistance with ADLs during the initial period after admission. The Medication Administration Record indicated ongoing monitoring for pain, anticoagulant therapy, and depression, but these interventions were not incorporated into a baseline care plan within the required timeframe. The lack of a timely baseline care plan was acknowledged by nursing staff, who stated that this could have resulted in the resident's needs not being met appropriately.