Incomplete Baseline Care Plan for Newly Admitted Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop and implement an adequate baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed the resident was admitted with multiple diagnoses, including a right femur fracture, type II diabetes mellitus, cognitive communication loss, and right hip pain. The baseline care plan, dated the day after admission, addressed only skin integrity of the right hip after surgery and did not include any other care areas or diagnoses. During an interview, the Unit Manager stated that a complete baseline care plan should include ADLs, fall risk interventions, wounds and skin care, advanced directives, and specialized care such as diabetic management. The Unit Manager confirmed that the resident’s baseline care plan was not complete and did not meet these expectations. The incomplete and inaccurate baseline care plan resulted in the absence of documented interventions for several of the resident’s admitting conditions.
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