Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident with pressure ulcers. The resident, whose diagnoses included aphasia following a nontraumatic intracranial hemorrhage, was admitted on 3/5/26 with physician orders for treatment of coccyx and right buttock wounds, including cleansing with wound cleanser, patting dry, applying calcium alginate with Medihoney, and covering with a border foam dressing. Record review on 3/9/26 showed that the resident’s chart contained no care plan or baseline care plan at that time, despite the active wound care orders. On 3/10/26, further record review showed that a baseline care plan for admission was not entered until 3/9/26 at 4:36 P.M., which was more than 48 hours after the resident’s admission. During interview, the ADON stated that a baseline care plan should be put into place within one to two days after admission. The facility’s written policy, provided by the Administrator, required that every resident have a baseline care plan completed and implemented within 48 hours of admission, with the admitting nurse initiating the baseline care plan assessment upon admission and the IDT assisting to ensure completion within the regulatory timeframe. The failure to have a baseline care plan in place for this resident within 48 hours constituted noncompliance with the facility’s policy and applicable regulation.
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