Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. Record review showed that this resident was admitted on an identified date, but there was no evidence of a baseline care plan in the Electronic Health Record. Further review revealed that the resident’s comprehensive care plan was not developed and implemented until a later date, well beyond the required 48-hour timeframe for a baseline care plan. During an interview, the DON confirmed that the facility did not develop and implement a baseline care plan for this resident and stated that her expectation is that every resident has a baseline care plan in place within 48 hours of admission. The report notes that if the facility fails to develop and implement a baseline care plan, residents might not receive the care and services they need.
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