Failure to Develop Baseline Care Plan With Goals and Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan that met all of a resident’s needs, with measurable goals and interventions, for one of three residents reviewed for quality of care. The resident was admitted on 12/24/2025 with diagnoses including a wedge compression fracture of the fourth thoracic vertebra (subsequent encounter with routine healing) and an unspecified fracture of the fourth thoracic vertebra. The resident’s care plan showed that a focus assessment for an ADL (Activity of Daily Living) deficit was initiated on the admission date, but no goals or interventions were documented for this focus area. On 02/03/2025 at 10:30 AM, the MDS/Care Plan Coordinator acknowledged that the resident’s care plan lacked goals and interventions for multiple focus areas and stated that care plans are considered comprehensive only when appropriate goals and interventions are in place. The facility’s comprehensive care plan policy dated 11/2012 states that the interdisciplinary team should attempt to schedule an initial meeting with the resident and/or representative within five days of admission to review the baseline plan of care. This deficiency centers on the absence of documented goals and interventions in the resident’s baseline care plan despite the resident’s identified ADL deficit and fracture-related diagnoses, and the facility’s own policy requiring timely review of a baseline plan of care by the interdisciplinary team.
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