Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was an elderly male admitted with a diagnosis of senile degeneration of the brain, a progressive neurodegenerative disorder associated with dementia. A comprehensive MDS showed a BIMS score of 99, indicating he was unable to complete the interview and had severely impaired cognition. He had a history of falls prior to admission and had experienced falls while in the facility. Record review of the electronic medical record on 3/11/26 showed there was no baseline care plan completed for this resident. Further record review showed that a comprehensive care plan initiated on 6/22/25 for this resident addressed only falls and behavioral symptoms, and did not include other required areas such as ADLs, transfers, social needs, and orders. Interviews with the MDS nurse, DON, and administrator confirmed that baseline care plans were expected to be initiated within 24–48 hours of admission and that, if a comprehensive care plan was used instead, it should include instructions for all key care areas. The facility’s written policy on baseline care plans required development of a baseline plan within 48 hours of admission, including initial goals, physician, dietary, and therapy orders, social services, and PASARR recommendations as applicable. Despite these expectations and policy requirements, the resident’s baseline care plan was not completed within the required timeframe.
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