Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required by facility policy and professional standards. For one resident with multiple diagnoses including cerebral infarction, anxiety disorder, polyneuropathy, peripheral vascular disease, and COPD, no baseline care plan was found in the electronic medical record. This resident required significant assistance with mobility, toileting, transfers, and dressing, and was cognitively intact. Interviews revealed confusion among staff regarding responsibility for initiating and completing baseline care plans, with the admitting nurse, DON, and MDS Nurse each cited as responsible at different times. The comprehensive care plan for this resident was not initiated until four days after admission. For another resident with diagnoses of diabetes mellitus, hypertension, heart failure, and depression, and who required maximal assistance for daily activities, no baseline care plan was completed upon admission. The resident was also cognitively intact and required set-up assistance for eating. Staff interviews indicated that the MDS Nurse was expected to complete the baseline care plan, while the DON was responsible for providing it to the family. The DON was unaware that the baseline care plan had not been completed and believed she had started the comprehensive care plan, but it was not finished. The care plan documentation was incomplete, only addressing surgical wound and medication monitoring, and not the resident's full needs. Record review confirmed that the facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the two residents in question. Staff interviews consistently acknowledged the importance of the baseline care plan for communicating resident needs, but there was a lack of clarity and follow-through in ensuring these plans were completed as required.