F0655

D

Failure to Develop Person-Centered Baseline Care Plan on Admission

Milwaukee, Wisconsin Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a person-centered baseline care plan within 48 hours of admission for a newly admitted resident. Facility policy required that a baseline care plan be developed within 48 hours of admission, including minimum healthcare information such as initial goals based on admission orders, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable. The policy also required that the admitting or supervising nurse gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative, then establish goals and interventions reflecting the resident’s stated goals and current needs, and that a supervising nurse verify within 48 hours that a baseline care plan had been developed. For this resident, the baseline care plan that was created did not contain specific, person-centered interventions and did not fully reflect the resident’s identified needs and hospital discharge instructions.

The resident was admitted with multiple diagnoses, including a wedge compression fracture of the second thoracic vertebra, bilateral pneumonia, type 2 diabetes mellitus, essential hypertension, chronic heart failure, Alzheimer’s disease, and dementia. The 5-day admission MDS documented a BIMS score of 4, indicating severely impaired decision-making, and showed that the resident required varying levels of assistance with ADLs, was always incontinent of bowel and bladder, was at risk for pressure injuries, and was on a mechanically altered diet. Hospital discharge documentation indicated the resident needed a TLSO brace, a puree/thin diet with no straws, small sips, upright positioning, 1:1 supervision, and medications crushed in puree. Hospital therapy notes documented that the resident was unable to complete self-care and functional mobility sufficient to return to the prior living situation, required alarms for safety, and needed moderate assistance for functional mobility with identified deficits in ADLs, mobility, cognition, safety awareness, and sequencing.

Despite these identified needs, the facility’s baseline care plan and CNA Kardex contained generic, incomplete, and non–person-centered interventions. The baseline care plan listed problems such as diabetes, oxygen use, pain, psychotropic medication use, fall risk, potential/actual skin integrity impairment, bowel and bladder incontinence, ADL self-care deficits, limited physical mobility, and a desire to discharge home, but many interventions were left blank or written in non-specific terms (e.g., “specify what assistance,” “specify frequency,” “provide pressure relieving device(s): (specify)”). The care plan did not document the need for 1:1 supervision, the pureed diet with no straws, or other specific hospital discharge instructions. Fall interventions were limited to generic measures such as keeping the call light within reach, educating about safety, and following facility fall protocol, without individualized strategies similar to the hospital’s use of bed and chair alarms. The Kardex, which CNAs relied on for daily care, mirrored these incomplete and non-specific interventions and did not include detailed fall-prevention or aspiration-prevention measures. During interviews, the DON acknowledged that the baseline care plan and Kardex were not specific and that staff would not have known how to care for the resident to keep the resident safe and support the highest level of independence.