F0655

D

Failure to Develop Timely and Complete Baseline Care Plans for New Admissions

Gallup, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The facility failed to develop and implement adequate baseline care plans within 48 hours of admission for two residents. For one resident admitted with multiple complex diagnoses, including hepatic encephalopathy, dysphagia, GERD, alcoholic cirrhosis, dementia with behavioral disturbance, pneumonia, secondary thrombocytopenia, vitamin D deficiency, sequelae of cerebral infarction, COPD, multiple limb contractures, cognitive communication deficit, epileptic seizures, and a history of suicidal behavior, the baseline care plan dated on the admission day did not address several of these conditions. Specifically, dysphagia, alcoholic cirrhosis of the liver, pneumonia, secondary thrombocytopenia, COPD, muscle contractures in all four limbs, epileptic seizures, and history of suicidal behavior were omitted from the baseline care plan. During interview, the DON confirmed these diagnoses should have been included and stated that the admitting nurse is responsible for reviewing all admission documents and including all relevant diagnoses in the baseline care plan.

For another resident, the facility did not develop any baseline care plan within 48 hours of admission. This resident’s face sheet listed major depressive disorder with psychotic features, brief psychotic disorder, suicidal ideations, insomnia, anxiety disorder, pain, generalized muscle weakness, lack of coordination, abnormalities of gait and mobility, and cognitive communication deficit. However, the baseline care plan for this resident was not created until ten days after admission, outside the required 48-hour timeframe. In interview, the DON confirmed the admission and care plan dates and stated that her expectation is that care plans are created within 48 hours.