F0655

D

Failure to Develop and Provide Resident-Specific Baseline Care Plans Within 48 Hours of Admission

Virginia Beach, Virginia Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and provide person-centered baseline care plans within 48 hours of admission for multiple newly admitted residents, as required by facility policy. For each of five sampled residents, the baseline care plan section in the admission Observation note contained only generic statements such as receiving medications as ordered, skilled care, pain medications as ordered, skin care to prevent breakdown, dietary needs as ordered, and assistance with activities of daily living as necessary. These baseline care plans did not include resident-specific conditions or treatments that were documented elsewhere in the medical record. The facility’s own policy stated that an interim baseline care plan would be developed within 48 hours of admission to ensure resident needs were met until the comprehensive care plan was completed.

For one resident admitted with a displaced fracture of the left femur, muscle wasting, type 2 diabetes, cerebral infarction, and protein calorie malnutrition, the admission notes documented an indwelling urinary catheter and two post-operative surgical wounds to the left hip. However, the baseline care plan did not identify the catheter or the surgical wounds, and the baseline care plan checklist was not completed until several days after it was due. The comprehensive care plan did not address the catheter until more than two weeks after admission and did not address skin integrity until nearly a month after admission. Another resident admitted with a non-traumatic acute subdural hemorrhage, nondisplaced fracture of the right humerus, dysphagia, diabetes with hyperglycemia, protein calorie malnutrition, and dementia had a neurosurgery recommendation for a soft collar at all times following a fall with head injury. The baseline care plan did not identify the fracture or the need for the soft collar, and the baseline care plan checklist was completed after its due date. The resident’s fall and humerus fracture were not included in care planning until several days after admission, and the resident reported not recalling any staff discussing their care or keeping them informed about their care needs.

Another resident admitted with a displaced transverse fracture of the right patella, protein calorie malnutrition, PTSD, anxiety, major depressive disorder, and acquired absence of the right upper limb had a surgical incision to the right knee with sutures, slough tissue, and a wound vac, as well as an IV antibiotic order. The baseline care plan did not identify the surgical wound, wound vac, or IV antibiotic, and the checklist was completed late. The comprehensive care plan did not include the antibiotic or wound vac until more than a week after admission. A further resident with a brain neoplasm, protein calorie malnutrition, hemiplegia, and bipolar disorder had antipsychotic, hypnotic, and antidepressant medications ordered upon admission, but these were not specified in the baseline care plan, and the checklist was completed after its due date. The comprehensive care plan did not address these psychotropic medications until nearly two weeks after admission, and the resident stated they were not aware of their plan of care and that no one had reviewed specific aspects of their care or discharge plan with them.

A fifth resident admitted with acute kidney failure, protein calorie malnutrition, sepsis, and spinal stenosis had wounds to the sacrum and both buttocks and was receiving antidepressant medication. The baseline care plan again contained only general statements and referenced skin issues with a direction to see orders/observations that were not attached to the document provided to the resident. The baseline care plan checklist was completed after its due date, and the comprehensive care plan did not include the antidepressant use or pressure wounds until several days after admission. Interviews with facility staff, including the SSD, DOR, LPN, MDS coordinator, and DON, confirmed that the baseline care plan was treated as a general, non–resident-specific document attached to the initial nursing observation, that completion often occurred beyond 48 hours (especially for Friday admissions), and that specific care needs were typically discussed later at a “Path” meeting held three to five days after admission. Staff also confirmed that the developed baseline care plan was not specific to resident care needs and was not provided to residents or representatives in a timely manner.