Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for one resident, identified as R #67. Record review showed that this resident was admitted with diagnoses including partial intestinal obstruction, essential hypertension, colostomy status, and a need for surgical aftercare following digestive system surgery. Review of the resident’s electronic health record revealed that no baseline care plan was present. In an interview, the DON confirmed that the baseline care plan had not been completed and acknowledged that it should have been in place.
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