Failure to Include PASRR Recommendations and Safety Device in Baseline Care Plan
Penalty
Summary
Surveyors identified that the facility failed to include required person-centered care information on the baseline care plan for one resident. The facility’s Baseline Care Plan policy dated 7/11/24 required that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information necessary to properly care for the resident, such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASRR recommendations when applicable. For the resident in question, who was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, and status post right hip revision, the baseline care plan was created but not dated and did not reflect all required elements. The resident’s PASRR Mental Illness Evaluation dated 1/8/26 documented recommendations for individual psychotherapy, community-based rehabilitative services, mental health case management, weekly or quarterly psychiatrist appointments for psychiatric prescription medication management, and development of a safety plan to address suicidal ideation. Additionally, a physician order dated 1/12/26 directed that the resident wear a knee immobilizer while lying in bed or sitting in a chair. Despite these documented recommendations and orders, the baseline care plan did not include the PASRR recommendations or the physician-ordered knee immobilizer. On 1/21/26 at 5:00 PM, the DON confirmed that these items were not included on the baseline care plan and acknowledged they should have been.
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