Failure to Complete Timely Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to complete baseline care plans (BCPs) within 48 hours of admission for two residents, contrary to its policy and regulatory expectations. Resident 1 was admitted on 1/7/2026 with dementia and documented stage 2 pressure ulcers on both sides of the buttocks. Although the BCP noted that the resident was admitted with stage 2 pressure ulcers, the BCP itself was not completed until 2/5/2026, nearly one month after admission. Additionally, Resident 1’s skin care plan/care plan for the pressure ulcers was not initiated until 2/5/2026, despite the presence of existing pressure ulcers at admission. Resident 2 was admitted on 2/2/2026 with dementia and muscle weakness, but the BCP for this resident was also not completed until 2/5/2026, exceeding the 48-hour requirement. During an interview and concurrent record review on 2/5/2026 at 11:17 a.m., the DON confirmed that facility policy required BCPs to be completed within 48 hours of admission and acknowledged that neither resident’s BCP met this timeframe. The DON also confirmed that the absence of a timely BCP and skin care plan could increase the risk of unsafe care, including risk for skin breakdown and wound worsening. A review of the facility’s Person-Centered Care Planning policy, revised 4/24/2025, indicated that the baseline care plan was to be developed and implemented within 48 hours of admission to promote continuity of care, communication among staff, resident safety, and safeguard against adverse events.
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