Failure to Develop Complete Baseline Care Plans on Admission
Penalty
Summary
The facility failed to develop accurate baseline care plans within 48 hours of admission for three residents, omitting key information necessary for their immediate care. For one resident admitted with a nondisplaced fracture of the right ulna, muscle weakness, and gait and mobility abnormalities, record review showed that the baseline care plan dated 12/27/25 did not include the resident’s use of a right wrist brace or oxygen, despite these needs being present. In an interview, the DON confirmed the baseline care plan date and acknowledged that the use of the wrist brace and oxygen were omitted from the baseline care plan. Another resident admitted with chronic idiopathic constipation, a personal history of digestive system disease, and cerebral palsy had a physician’s order for daily Lactulose for constipation, but the baseline care plan dated 01/20/26 did not address the chronic idiopathic constipation or related care and support needs. The UM confirmed that this omission did not meet her expectations. A third resident admitted with a displaced intertrochanteric fracture of the left femur, a displaced comminuted fracture of the left radius, difficulty walking, and age-related osteoporosis had a baseline care plan dated 01/02/26 that addressed ADL assistance, diabetes, fall risk, pain, psychotropic drug risk, and skin breakdown risk, but did not address wound care for a surgical hip wound present on admission. The UM confirmed the resident arrived with a surgical hip wound and that wound care should have been included in the baseline care plan but was not.
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