F0655

D

Failure to Complete Timely Baseline Care Plan and Initial Care Conference

Noblesville, Indiana Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to initiate and conduct a 72-hour care plan meeting and develop a person-centered baseline care plan within the required timeframe following a resident’s admission. The resident, who had diagnoses including a right femur neck fracture post-surgical repair, cognitive symptoms following a cerebrovascular accident, repeated falls, hypertension, conversion disorder with seizures or convulsions, osteoporosis, and chronic pain, was admitted on an identified date. The admission MDS showed moderate cognitive impairment, wheelchair use for mobility, frequent urinary incontinence, occasional bowel incontinence, and impairment of one lower extremity. The clinical record lacked documentation that a 72-hour care plan meeting was initiated or conducted within the required timeframe, and the initial care conference did not occur until nine days after admission.

Interviews with staff revealed that the Social Service Director typically called resident representatives 24 to 48 hours after admission to set up a care conference and generally did not document unsuccessful attempts to reach representatives. The Admission Coordinator reported leaving a voicemail for the resident’s representative on the first available business day after admission due to a holiday, and the Transitional Care Nurse acknowledged that the care conference for this resident was delayed to accommodate the representative’s schedule, who wanted to be present. The facility’s policy required development of a person-centered baseline care plan within 48 hours of admission, including medications, dietary instructions, services, treatments, and pertinent updates by the date of the initial IDT care conference, but this was not completed as required for this resident.