Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure baseline care plans were developed and completed within 48 hours of admission, as required by facility policy. The facility’s Baseline Care Plans policy, revised 10/15/22, states that a baseline plan of care is to be developed within 48 hours of admission to address the immediate needs of residents and used/updated until a comprehensive care plan is implemented. For one resident with end stage renal disease and acute respiratory failure with hypoxia, the baseline care plan was initiated on 2/2/26 but was not locked or completed until 2/3/26, which exceeded the 48-hour requirement. The RN Clinical Resource Nurse and the CNO both stated that a baseline care plan is not considered completed until it is locked, and the RN Clinical Resource Nurse acknowledged that this resident’s baseline care plan had not been completed within 48 hours and should have been. A second resident, who had diagnoses including necrotizing fasciitis and diabetes with diabetic polyneuropathy, was also found to have a baseline care plan completed outside the required timeframe. A closed record review showed that this resident’s baseline care plan was not completed until 12/29/25, which was 5 days after admission. The RN Clinical Resource Nurse stated that the baseline care plan for this resident should have been created within 48 hours of admission and had not been. These findings demonstrate that for 2 of 3 residents reviewed for baseline care plans, the facility did not complete the baseline care plans within the 48-hour timeframe specified in its own policy, resulting in care plans that did not provide timely direction for care.
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