Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for one newly admitted resident, as required by facility policy. Record review showed that this resident, a female with diagnoses including frontal lobe and executive function deficit following cerebral infarction, psoas abscess, and aphasia, was admitted on an identified date, but no baseline care plan was present in the electronic medical record as of 02/05/2026. The resident’s MDS assessment was also noted to be incomplete. The facility’s written Care Planning Policy and Procedure states that a baseline care plan will be completed within 48 hours of admission to provide a comprehensive plan of care addressing the resident’s needs, strengths, goals, and approaches. During interviews, the DON confirmed that a baseline care plan should be completed within 48 hours after admission and stated that the MDS Coordinator was responsible for completing these plans. The DON acknowledged that Resident #1 did not have a baseline care plan and stated she did not know why it had not been completed. The MDS Coordinator (LVN A) also confirmed responsibility for baseline care plans, acknowledged that the baseline care plan for this resident was missed, and stated she did not know why it was not completed. She indicated that baseline care plans are important for staff to follow for new admissions and that, in the absence of such a plan, CNAs were expected to ask the nurse supervisor if they needed to know what care a resident required.
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