Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the resident, an older female with Alzheimer’s disease, vascular dementia, acute cystitis, and a history of stroke, was admitted on an identified date, but no baseline care plan was completed within 48 hours following admission. Her admission MDS documented a BIMS score of 02 indicating severe cognitive impairment, the presence of delusions and physical behavioral symptoms directed toward others, use of a walker with need for touch assistance and supervision to ambulate, partial to moderate assistance with transfers, bowel and bladder incontinence, and receipt of scheduled pain medication. Despite these identified needs, the baseline care plan form in the EMR was not completed as required. During interviews, the Clinical Care Nurse (CCN) stated that the EMR form titled “Baseline care plan” for this resident was not completed and that the prior DON had been responsible for delegating the task, but she was unsure who had been assigned to complete it. The MDS nurse reported that the “Baseline Care Plan” form in the EMR had been deleted and was not completed, and although her name appeared on the deleted form, she did not know who deleted it or why it was not completed. Both staff members acknowledged that this failure could put residents at risk for not getting needed care. Review of the facility’s policy titled “Care Plans – Baseline” dated November 14, 2023, confirmed that a baseline plan of care to meet the resident’s immediate needs must be developed within 48 hours of admission, and that the interdisciplinary team is to review practitioner orders and implement a baseline care plan including initial goals, physician and dietary orders, therapy and social services, and provide a copy to the resident or representative.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.