Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled "Assessments in Long Term Care" required licensed nursing staff to initiate an admission assessment upon the resident’s arrival and complete nursing and screening assessments within 24 hours, with the nursing care plan initiated based on identified needs from that assessment. The facility’s initial care plan form was to include admission status, identification of the responsible party or resident offered a copy of the initial care plan, and information on resident medications. For the resident in question, the face sheet showed an admission date of 01/26/26 with diagnoses including multiple pelvic fractures, and progress notes documented arrival from the hospital that afternoon. The admission MDS dated the same day showed intact cognitive skills and a need for partial/moderate assistance with toileting and personal hygiene, and substantial/maximal assistance with showering, bathing, and lower body dressing. Despite these documented needs, review of the medical record showed no documentation that a baseline care plan was completed for this resident. The MDS Coordinator/RN stated that the admitting charge nurse is responsible for completing the baseline care plan upon admission, using a computer template, and that it should be completed within 24 hours along with admission notes; however, the RN confirmed there was no baseline care plan for this resident. Another MDS Coordinator/LPN reported that they perform an admission audit within 48 hours, circling incomplete items and returning them to the nurses’ desk, and acknowledged that staff did not complete the baseline care plan, though they believed it had been done and that the next nurse should complete any missing items. RN C stated nursing staff should complete the baseline care plan upon admission. The DON and the Administrator both indicated that the admitting nurse or nurse on duty is expected to complete the baseline care plan, including assessments and offering a copy to the resident and/or family, but this did not occur for the resident involved.
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