F0655

E

Failure to Complete Baseline Care Plans Within 48 Hours of Admission

Clemmons, North Carolina Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop baseline care plans within 48 hours of admission for multiple residents. For nine of thirty sampled residents, there was no documented evidence that a baseline care plan had been completed, despite diagnoses and conditions that required coordinated care. These residents included individuals with paraplegia and neuromuscular bladder dysfunction, closed fracture, dementia, type 2 diabetes, hypothyroidism, hypertension, dementia with a history of falls, protein calorie malnutrition, chronic wounds, acute on chronic systolic congestive heart failure, acute respiratory failure, displaced femur fracture, chronic obstructive pulmonary disease (COPD), influenza, pneumonia, fractures of the hand and pelvis, diabetes, chronic pain syndrome, and other serious conditions. In each case, record review showed that the baseline care plan was either missing or had not been developed by the time of the surveyor’s review.

Staff interviews revealed a lack of awareness and inconsistent understanding of responsibility for completing baseline care plans. Unit managers repeatedly stated they were not aware that baseline care plans had not been completed for specific residents and confirmed, after attempting to locate them, that they did not exist. The DON consistently stated that the admitting nurse was responsible for completing the baseline care plan, with the expectation that if the admitting nurse did not complete it, the oncoming nurse or unit manager would do so within the required timeframe. However, the DON also acknowledged not knowing why the baseline care plans had not been completed for several residents. In some interviews, unit managers stated that the baseline care plan was part of the admission process and should be completed at the time of admission, while in other interviews, staff indicated that the baseline care plan was not included in the list of required admission assessments.

Additional interviews highlighted confusion and lack of training among nursing staff regarding who was responsible for baseline care plan completion. One nurse who admitted a resident with influenza, pneumonia, and COPD stated that the baseline care plan was not on the list of assessments to be completed for new admissions and believed the unit manager would complete it, even though she was aware of the 48-hour requirement. Another nurse assigned to a resident with multiple pelvic fractures and COPD did not complete the baseline care plan, believing the unit manager was responsible. The unit manager who assisted with that admission stated she did not complete the baseline care plan because she had not yet been trained and thought the admission nurse was responsible. Administrators interviewed were not aware that baseline care plans had not been completed for the affected residents, though they stated they expected baseline care plans to be completed within the regulatory timeframe.

Across all nine residents cited, the common factors leading to the deficiency were the absence of completed baseline care plans in the medical records within 48 hours of admission and inconsistent or incorrect assumptions among staff about who was responsible for completing them. The surveyors’ findings were based on record reviews that failed to show any baseline care plans and on staff interviews that confirmed the plans had not been developed, despite staff acknowledging that such plans should be completed within 24–48 hours of admission to address residents’ immediate needs.