Incomplete Baseline Care Plans After Admission: Surveyors found that baseline care plans were not completed timely or were only assessment forms without interventions for multiple residents with conditions such as dementia, schizophrenia, diabetes, COPD, wounds, pain, falls, and oxygen dependence. The MDS/LPN could not locate several baseline care plans, and the DON confirmed the plans were not being completed appropriately and residents were not being given copies as required by policy.
A facility failed to provide baseline care plans within the required timeframe for multiple residents after admission. Records and interviews showed that residents with significant medical needs, including cardiopulmonary conditions, cognitive impairment, dysphagia, and renal dialysis dependence, did not receive or sign their baseline care plans until later, and in several cases there was no documentation that the resident or representative had been given a copy or informed of the plan.
Surveyors determined that the facility did not develop a complete baseline care plan for a newly admitted resident with dementia and postprocedural intestinal obstruction. The MDS showed the resident had severely impaired cognition and required staff assistance with ADLs, but the baseline care plan only noted an ADL self-care performance deficit related to comorbidities without specifying the resident’s basic ADL care needs. An LPN confirmed the plan lacked essential information needed to provide care, and policy review showed that baseline care plans were required to include details on ADL assistance needs.
Surveyors found that the facility failed to develop and implement timely and complete baseline care plans for two newly admitted residents. One resident with multiple chronic conditions and extensive ADL assistance needs had no baseline care plan in place for nearly two weeks after admission, and monitoring for diabetes was not initiated until a comprehensive care plan was developed later. Another cognitively intact resident with multiple medical diagnoses had a baseline care plan that did not address oxygen administration, even though the resident was observed using oxygen via nasal cannula at 4 L/min and used oxygen as needed. Facility policy required the admission nurse to initiate a baseline care plan and required care plans to include objectives to meet medical needs.
A resident admitted with impaired cognition, dependence in ADLs, wheelchair use, and multiple medical conditions was identified as a fall risk on admission, yet no fall interventions were documented as in place at that time. The resident experienced several falls before a comprehensive fall care plan was initiated, and the baseline care plan—required within 48 hours per facility policy—was not completed until much later, with limited fall interventions documented. An MDS coordinator confirmed the delay in completing the baseline care plan and the absence of documented fall interventions on admission.
A resident admitted with multiple medical conditions, including COPD, was documented on the MDS and Nursing Comprehensive Evaluation as cognitively intact with moderate hearing difficulty, but the baseline care plan did not include any problem, goal, or interventions related to hearing impairment. Social services staff reported they were unaware of any hearing issues, and the DON and ADON acknowledged that moderate hearing impairment should have triggered inclusion in the baseline care plan and that no audiology services were discussed. This failure did not follow the facility’s care planning policy requiring identification of immediate needs and interventions within 48 hours of admission.
A resident admitted with multiple serious conditions, including COPD, sepsis, lung cancer, heart failure, pneumonia, oxygen dependence, and recent fall-related injuries, did not receive a timely and complete baseline care plan. The nursing admission assessment on the admission date was left largely blank, including the section indicating whether the resident or representative received an Admission/Baseline Care Plan Summary. The baseline care plan created on the admission date contained only minimal information, and a second, more complete baseline care plan was not developed until several days later and was not documented as provided to the resident or representative. Although additional problem-specific care plans were initiated shortly after admission, they did not meet the requirement for either a baseline care plan or a comprehensive care plan within 48 hours, and the DON acknowledged that baseline care plans were not being completed within the required timeframe.
The facility failed to develop and implement timely baseline care plans and to provide summaries of those plans to residents or their representatives. One newly admitted resident had no baseline care plan within 48 hours. Another resident with multiple fractures, dementia, and heel wounds had detailed hospital AVS instructions for wound care, positioning, and hip precautions, but the baseline care plan only addressed an ID band and COVID-19 infection risk, omitting skin assessment, wound care, hip precautions, and personal care needs. A third resident admitted with a Stage III sacral pressure ulcer and multiple comorbidities had a baseline care plan marked as not applicable for wound care, with no pressure-ulcer interventions until days later, and no documented provision of a baseline care plan summary to the resident or a representative. The facility’s care planning policy required a baseline care plan within 48 hours but did not address providing a summary to residents or representatives.
Baseline care plan not provided or acknowledged. A resident admitted with multiple chronic conditions, including DM, emphysema, HF, Afib, sleep apnea, HTN, and neuropathy, had intact cognition on the admission MDS. The resident stated he had not received a care conference, discharge planning meeting, or a copy of the baseline care plan. An LPN verified the baseline care plan lacked the resident’s signature and acknowledgement and was not dated by the DON.
A resident admitted with multiple medical conditions, including a displaced humerus fracture and rheumatic mitral stenosis, had hospital discharge orders and facility orders for PRN Oxycodone for pain but went 36 hours without receiving it. The baseline care plan completed within 48 hours of admission did not assess or address the resident’s pain or documented hearing loss with use of hearing aids, despite the resident being cognitively intact and reporting excruciating pain and hearing impairment. An MDS coordinator later confirmed that pain management and hearing loss should have been included in the baseline care plan, contrary to facility policy requiring essential healthcare information in baseline care plans.
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