Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors found that the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was an older adult admitted with a primary diagnosis of cerebral infarction, had an intact BIMS score of 13, had a Foley catheter, and was incontinent of bowel. The initial MDS confirmed these conditions. Review of the resident’s baseline care plan in the PCC electronic health record revealed it was essentially not completed, containing only a single fall-risk entry with a focus on risk for falls related to gait and balance problems and fear of falling, along with associated goals and interventions. No other baseline care plan components or instructions for care were documented. During interviews, the Social Worker confirmed that the baseline care plan in PCC for this resident was not completed and stated that every discipline of the IDT was responsible for ensuring their section was complete, acknowledging that they “must have missed that one.” The Social Worker identified that if the care plan was not present, staff did not know what care they needed to provide. The DON also reviewed the resident’s record in PCC, checked the miscellaneous tab where documents were sometimes scanned, and confirmed that the baseline care plan was not in the chart. The DON stated she usually checked care plans in PCC but had missed this one and acknowledged that the care plan was needed so staff would know what to do, describing it as the staff’s plan of care. The facility’s policy stated that the IDT is responsible for development of resident care plans according to timeframes and criteria established by §483.21.
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