F0655

E

Incomplete Baseline Care Plans and Missing PASARR Information for New Admissions

Richland, Washington Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement complete baseline care plans (BCPs) within 48 hours of admission for three residents, as required by facility policy and regulation. The facility’s Baseline Care Plan policy required that each new resident have a BCP developed within 48 hours of admission, including essential healthcare information, initial goals based on admission orders, physician and dietary orders, therapy services, social services, and PASARR recommendations. Surveyors found that for all three reviewed residents, the BCPs were incomplete and did not include required elements such as specific medication needs, mental health diagnoses, PASARR Level II information, and code status.

For one resident admitted with respiratory failure with hypoxia, hypoparathyroidism, anxiety, and insomnia, the comprehensive assessment showed the resident needed set-up to partial assistance for ADLs and supervision/touch assistance for transfers, with intact cognition. However, the BCP dated shortly after admission lacked focus areas, goals, or interventions related to multiple ordered medications, including quetiapine, acetazolamide for edema, Synthroid/levothyroxine (with a specific order requiring brand-name Synthroid), temazepam, hydroxyzine, and continuous oxygen use. The BCP also did not include the resident’s preferences for medical treatment in emergent situations (code status) or any information regarding the resident’s Level II PASARR recommendations, despite transfer orders specifying the brand-name Synthroid requirement.

For a second resident admitted following hip replacement surgery with diagnoses including long-term anticoagulant use, anxiety, and depression, the comprehensive assessment showed substantial assistance was needed for showers, lower body dressing, and transfers, and that cognition was moderately impaired. The BCP for this resident contained no focus areas, goals, or interventions addressing the anxiety disorder, PASARR, or PASARR Level II recommendations, and did not document preferences for medical treatment in emergent situations. For a third resident admitted with a broken hip, PTSD, and anxiety, who required substantial to maximal assistance for ADLs and had intact cognition, the BCP lacked any focus areas, goals, or interventions related to PTSD or PASARR Level II recommendations. Staff interviews confirmed that the BCP process relied on a user-defined assessment in the electronic record, that code status did not auto-populate and had to be entered manually, and that PASARR and social services sections, including Level II information and dates, were the responsibility of social services but were not completed for these residents.