Failure to Complete Individualized Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, person-centered baseline care plans within 48 hours of admission for three residents, as required by its Plan of Care Policy and Procedures. The policy, revised on 9/25/17, required that an individualized baseline plan of care be created within 48 hours of admission, including initial goals and interventions based on admission orders, physician orders, dietary orders, therapy services, social services if applicable, and other areas needed to provide effective care until the comprehensive care plan was completed. Record review for one resident admitted for rehabilitation after a fall at home showed that the baseline care plan was essentially blank, containing only the spouse’s signature on one page and lacking any initial goals, instructions, or interventions, including failure to address the resident’s history of falls or to identify goals and interventions to prevent further falls. Record review for a second resident admitted from the hospital with chest pain for rehabilitation services showed that the baseline plan of care had an incomplete first page, and while a goal for falls/safety was circled, no interventions were identified for that goal. For a third resident admitted from the hospital with acute respiratory failure with hypoxia for rehabilitation services, the baseline plan of care also had an incomplete first page, and the goals for falls/safety, oral/dental, pain, and anticoagulant use were circled without any corresponding interventions documented. In interviews, the unit manager stated that the admitting nurse was required to complete a comprehensive assessment and personalized baseline care plan at admission and that she reviewed new admissions the next day to ensure orders, assessments, and baseline care plans with goals and personalized interventions were completed. Both the unit manager and the DON confirmed, upon review, that the baseline care plans for these three residents were incomplete and did not include the required goals and interventions needed to meet residents’ needs until the comprehensive plans of care were completed.
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