F0655

D

Failure to Complete and Communicate Baseline Care Plan Within 48 Hours of Admission

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted following hospitalization for a left cerebellar intracranial hemorrhage and had multiple diagnoses including intracranial hemorrhage, dysphagia, morbid obesity, atrial fibrillation, heart disease, TIA, and cognitive impairment. The admission MDS documented that the resident used a walker and manual wheelchair and required substantial/maximal assistance with bathing, dressing, rolling, and was dependent on staff for toileting hygiene, with a BIMS score of 15 indicating intact cognition. Despite these documented needs, the baseline care plan initiated on the date of admission focused on hypertension, arrhythmia, risk for bleeding, risk for decreased cardiac output, altered neurological status, and later impaired physical mobility, but did not address the resident’s ADL needs.

Surveyor review showed that the baseline care plan did not document whether the resident required assistance with toileting, dressing, eating, transfers, bathing, and personal cares. The care plan documented impaired physical mobility and use of a safety device wheelchair only later, with the wheelchair intervention dated 20 days after admission, indicating that the resident’s mobility needs were not addressed in the baseline care plan within the required timeframe. Additionally, the surveyor’s review of the electronic medical record did not reveal evidence that a baseline care plan summary was provided to the resident.

Further record review identified active medication orders for constipation (polyethylene glycol and sennosides), depression (trazodone), and anticoagulation for atrial fibrillation (Eliquis). The baseline care plan did not include the resident’s concerns or needs related to depression, use of an anticoagulant, or constipation. During an interview, the resident stated that staff had not reviewed care plan interventions or provided a copy of the care plan. The DON reported that admitting nurses complete assessments and a temporary care plan for skin and falls, and that MDS staff, therapy, and regional nurses are involved in creating baseline care plans, but there was no evidence in the record that a complete baseline care plan, including ADLs and the identified clinical issues, was developed and shared with the resident within 48 hours of admission.