Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified that the facility failed to create and implement a Baseline Care Plan within 48 hours of admission for one resident. Record review showed that this resident was admitted with diagnoses including Parkinson's disease, dementia, and epilepsy. The resident’s face sheet confirmed the admission date, but review of the care plan revealed that no baseline care plan was developed within the required 48-hour timeframe; instead, the care plan initiation date was documented as 12/22/2025, which was after the 48-hour window. In an interview, the DON stated that nursing staff are responsible for initiating the baseline care plan and acknowledged that her expectation was for the baseline care plan to be completed within 48 hours of admission, which did not occur for this resident. This deficiency was based on record review of the resident’s admission documentation and care plan dates, as well as the DON’s interview confirming both the facility’s process and the failure to meet the 48-hour requirement for baseline care plan completion.
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