Failure to Complete Comprehensive Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop a complete baseline care plan within 48 hours of admission for one resident. The resident was admitted and later discharged within a few days, with documented diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right toes, kidney transplant status, difficulty walking, reduced mobility, and acute osteomyelitis of the right ankle and foot. Physician orders at admission included multiple high‑risk medications and treatments: azathioprine for immunosuppression, Eliquis as an anticoagulant, gabapentin for neuropathic pain, insulin for diabetes, and IV antibiotics (linezolid for VRE and meropenem). These orders and diagnoses established several immediate clinical needs at the time of admission. Record review showed that the baseline care plan dated the day after admission did not address key areas related to the resident’s immediate needs, specifically pain management, antibiotic use, weight‑bearing status, anticoagulant use, and hypoglycemia related to insulin therapy. In an interview, the DON confirmed that the baseline care plan failed to include these elements and acknowledged that the baseline care plan should be completed within the first 48 hours of admission, which did not occur as required. This omission formed the basis of the cited deficiency.
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