Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. The resident, who had emphysema, a history of cerebral infarction, and repeated falls, was readmitted to the facility and had a Nursing re-admission Assessment Tool completed by a nurse. This assessment included information on mental and physical health, pain, Braden Scale, tuberculosis screening, fall risk/medication, smoking safety, device/air mattress safety, and elopement risk. However, review of the electronic medical record showed that no baseline care plan was completed following this admission. A comprehensive care plan was not initiated until several days after admission and, as of the survey review date, contained only one focus area related to nutritional status. During interviews, the DON stated that a baseline care plan was normally completed by the admitting nurse within 24 hours of admission and confirmed that none was present for this resident. The Unit Manager reported that the admitting nurse completed a re-admission assessment instead of the required admission assessment, and that the re-admission form did not include the baseline care plan component with focus areas, goals, and interventions. The admitting nurse stated she completed the forms that were auto-populated in the electronic system and did not know that the admission Nursing Collection Tool form was required to generate a baseline care plan.
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