Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors determined that the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission for one of three newly admitted residents with pressure ulcers. Record review on 3/19/26 at 11:20 A.M. showed that Resident C, whose diagnoses included paraplegia, chronic pain, and anxiety, was admitted on an identified date but had no baseline care plan in place. During an interview on 3/20/26 at 1:35 P.M., the DON stated that Resident C’s initial baseline care plan should have been completed. On 3/20/26 at 1:08 P.M., RN 4 provided the facility’s policy, dated 3/23/21, which requires that every resident have a baseline care plan completed and implemented within 48 hours of admission to promote continuity of care and communication among staff, increase resident safety, safeguard against adverse events most likely to occur after admission, and ensure the resident and representative receive a written summary of the initial plan of care. This requirement was not met for Resident C. This citation relates to intakes 2803022 and 2799537 and 410 IAC 16.2-3.1-30(a).
