F0655

D

Failure to Develop and Implement Timely Baseline Care Plan on Admission

Arlington, Texas Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission, or to have a comprehensive care plan in place within that same timeframe, for one resident. The resident was an adult male admitted with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, conditions associated with confusion, memory issues, and personality changes. On admission, an LVN documented that the resident was admitted to a secured unit from another nursing facility, arrived on a stretcher, had poor memory, used a wheelchair, and required two-person assistance for transfers, hygiene, and bathing. A skin assessment at admission identified bruising and small scabs on his body.

Record review on a later date showed that the resident’s electronic medical record contained no care plans on the care plan page, and the admission MDS was still being edited. Progress notes from admission through several days afterward documented multiple care concerns, including fall risk and actual falls, skin tears, hospice services, agitation, and confusion, but there was no corresponding baseline care plan in the EMR during that period. A Baseline Care Plan Acknowledgment form indicated that the resident and his representative were given a copy of a baseline care plan several days after admission, yet the EMR still showed no care plans until a later date, when multiple care plans (ADLs, medications, skin, cognition/dementia, communication, falls, and behaviors) were all initiated on the same day.

Interviews with staff further clarified the lack of a documented baseline care plan. The admitting LVN stated she did not know where baseline care plans were kept, though she entered admission information in her note. The Regional RN explained that baseline care plans were created in the same section as regular care plans and acknowledged that there were no care plans visible for this resident at the time of review. The ADON reported that he had provided a baseline care plan acknowledgment to the resident’s responsible party after a verbal discussion of the plan of care but admitted there was no documented baseline care plan, stating he must have forgotten to enter it. The facility’s own baseline care plan policy required completion and implementation of a baseline care plan within 48 hours of admission, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations, and required documentation that a written summary was provided to the resident and representative, which was not met in this case.