Failure to Complete Timely and Accurate Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, complete baseline care plans within 48 hours of admission for multiple residents. For one resident admitted with fractures of the left humerus and right radius, depression, and anxiety, record review showed that the baseline care plan, dated several days after admission, was not completed and signed until thirteen days post-admission, missing the 48-hour requirement. The DON confirmed that this baseline care plan did not meet her expectations due to the late completion. Another resident admitted with a sacral fracture, HTN, osteoarthritis, and urinary retention had a baseline care plan marked completed on the admission date but not signed by the last author (the activity director) until eighteen days after admission, also missing the 48-hour deadline, which the DON acknowledged did not meet her expectations. A third resident admitted with a displaced intertrochanteric femur fracture, chronic respiratory failure with hypoxia, collapsed lumbar vertebra, wedge compression fractures at T11–T12, gastrostomy status, history of chemotherapy and irradiation, and long-term anticoagulant use was observed with a feeding pump connected to a gastrostomy tube. The MDS documented current tobacco use and anticoagulant therapy, but the baseline care plan did not indicate that the resident was a current smoker, did not document current anticoagulant use, and contained no information in the nutritional services section. The DON stated that this baseline care plan did not meet her expectations because it omitted the resident’s smoking status, anticoagulant use, and feeding tube.
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