F0655

D

Failure to Develop Baseline Care Plan Within 48 Hours of Admission for High Fall-Risk Resident

Tucson, Arizona Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for a newly readmitted resident, as required by 42 CFR §483.21(a)(1). The resident was readmitted with diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. An admission clinical evaluation documented that the resident arrived by wheelchair and was alert and oriented times three with some forgetfulness, and the physician’s admission history noted a recent two‑day history of weakness, falls at home, inability to ambulate, and dizziness. An admission Morse Fall Scale completed the day of admission showed a score of 65, indicating high fall risk. Despite these findings, review of the medical record revealed that no baseline care plan was developed within 48 hours of admission to provide instructions to meet the resident’s immediate needs.

A comprehensive care plan was not initiated until two days after admission. That care plan identified an ADL self‑care performance deficit related to deconditioning and risk for falls related to deconditioning and gait/balance problems, and included interventions such as encouraging participation in care, ensuring the call light and commonly used items were within reach, and anticipating and promptly responding to needs. Prior to this comprehensive care plan, there was no documented baseline care plan outlining initial goals, physician orders, dietary orders, therapy services, social services, or other minimum health information necessary to guide staff in providing person‑centered care immediately after admission. The absence of a baseline care plan occurred despite the facility’s own fall prevention policy, which required timely assessment and initiation of individualized interventions for residents at risk for falls.

Following admission, the resident experienced multiple falls. Nursing documentation described unsteady gait, poor balance, and the resident’s refusal to follow instructions and insistence on going to the bathroom independently, even while wearing briefs. Progress notes recorded that the resident was found on the floor on more than one occasion, with neuro checks initiated after each event and vital signs monitored. An admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. In a subsequent interview, the RN stated that the unit manager is responsible for initiating the baseline care plan and confirmed that no baseline care plan was found for this resident in the electronic medical record. The DON also acknowledged that the resident’s fall care plan did not reflect the high fall risk identified in the fall assessment and that the care plan was not updated after the resident’s fall incidents. These findings collectively demonstrate that the facility did not develop and implement a baseline care plan within 48 hours of admission to address the resident’s immediate needs as required by regulation and facility policy.

The facility’s fall prevention policy, adopted several months before the events, specified that each resident would be evaluated upon admission and that the IDT would review fall risk assessments and initiate fall prevention protocols as appropriate. It also stated that the DON or designee would ensure that residents identified at risk for falls or who had experienced a recent fall had all recommended interventions in place, with current assessments and documentation reflecting notification of applicable disciplines, the physician, and the resident’s family or responsible party. Despite this written process, the resident’s record lacked a timely baseline care plan and did not initially incorporate the high fall risk status into the care planning process, contributing to the cited deficiency.