Failure to Include ADL Needs in Baseline Care Plan
Summary
Surveyors found that the facility failed to implement an adequate baseline care plan addressing activities of daily living (ADL) needs for a newly admitted resident. The resident was admitted with diagnoses including postprocedural intestinal obstruction and dementia, and the MDS assessment documented severely impaired cognition and a need for staff assistance with ADLs. The baseline care plan, dated on the admission day, only noted that the resident had an ADL self-care performance deficit due to comorbidities and did not include further details about the resident’s basic ADL care needs. An interview with the MDS LPN confirmed that the baseline care plan lacked the basic information needed to care for the resident. Review of the facility’s Baseline Care Plan/48 Hour Care Plan policy showed that baseline care plans were required to include information regarding resident needs for assistance with ADLs, which was not done in this case. This deficiency was cited for one resident out of 13 reviewed for baseline care plans, with a facility census of 112 residents, and was investigated under Complaint Number 2963128.
Penalty
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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.
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.
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.
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.
Failure to Develop and Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement baseline care plans within the required timeframe and to provide them to the resident’s representative. One resident was admitted with multiple diagnoses including COPD, anxiety, Type II diabetes mellitus, heart disease, and restless legs, and required substantial to maximal assistance with ADLs such as toileting, bathing, dressing, transfers, and mobility. Review of the nursing admission/readmission evaluation showed that this resident needed physical assistance for ambulation, transfers, toileting, and bathing and used a walker and manual wheelchair. However, no baseline care plan was initiated at admission. The MDS Coordinator confirmed that no baseline care plan was in place from admission until nearly two weeks later, with the first care area initiated 13 days after admission and monitoring for diabetes mellitus not started until 14 days after admission. A second resident was admitted with diagnoses including peptic ulcer, schizoaffective disorder, bipolar disorder, rheumatoid arthritis, anxiety disorder, COPD, and lung cancer. Social services documentation indicated this resident was cognitively intact, had adequate vision and hearing, could be understood, and did not display behaviors or refusals of care. A baseline care plan was in place, but it did not address the administration of oxygen. Observation showed the resident wearing an oxygen nasal cannula connected to an oxygen concentrator running at 4 L/min, and the Administrator confirmed there was no care plan developed to include oxygen administration, despite the resident using oxygen as needed. Facility procedures stated that the baseline care plan would be initiated by the nurse conducting the admission assessment, and facility policy required care plans to include objectives to meet residents’ medical needs.
Failure to Implement Timely Baseline Care Plan and Fall Interventions
Penalty
Summary
The facility failed to develop and implement a baseline care plan with appropriate fall interventions within 48 hours of admission for a resident identified as being at risk for falls. The resident was admitted with diagnoses including a displaced fracture of the right humerus with routine healing, chronic kidney disease, and anxiety disorder, and had moderately impaired cognition, was dependent for toileting and bathing, and used a wheelchair for mobility. The admission assessment documented the resident as a fall risk, and the medical record showed multiple falls on 03/20/26, 03/27/26 (two falls), and 04/10/26. A comprehensive care plan identifying the resident as at risk for falls, with interventions such as bedside mats, bed in lowest position, call light reminders, non-skid socks, ensuring basic needs were met, PT/OT, following fall protocol after incidents, monitoring for changes in mental status, and proper footwear, was not initiated until 03/24/26. The baseline care plan, which by facility policy was required to be developed within 48 hours of admission and include instructions needed to provide effective, person-centered care, was not completed until 04/05/26, well after admission and after multiple falls had occurred. The baseline care plan’s documented fall risk interventions were limited to encouraging use of the call light for assistance with ADLs and transfers. During interview, the MDS Coordinator confirmed that the baseline care plan with fall interventions was not completed until 04/06/26 and verified that no fall interventions were documented as being in place at the time of admission, despite the resident’s identified fall risk and subsequent fall events.
Failure to Address Hearing Impairment in Baseline Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to include a resident’s hearing status and related interventions in the baseline care plan within 48 hours of admission. The resident was admitted with diagnoses including anemia, vesicointestinal fistula, spinal stenosis, congenital kyphosis, and COPD, and was later discharged. Review of the most recent MDS 3.0 assessment showed the resident was cognitively intact and had moderate difficulty with hearing. A Nursing Comprehensive Evaluation also documented moderate hearing difficulty. Despite these documented findings, the baseline care plan contained no problem, goal, or interventions addressing the resident’s hearing impairment. Interviews with the Social Service Assistant and Social Service Director revealed they were not aware of any hearing issues or impairment for this resident. During an interview, the DON and ADON confirmed that a resident with moderate hearing impairment should have this condition addressed in the baseline care plan and acknowledged that it was not included for this resident. The DON also confirmed there had been no discussion of audiology services with the resident. Review of the facility’s Care Planning policy, dated 03/03/25, indicated that a baseline care plan must be developed within 48 hours of admission to identify immediate needs, initial goals, and interventions for effective, person-centered care. The omission of the resident’s hearing impairment from the baseline care plan constituted non-compliance under Complaint Number 2978380.
Failure to Develop and Communicate Timely Baseline Care Plans on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement baseline care plans within 48 hours of admission and to provide a summary of those plans to residents or their representatives. One newly admitted resident with diagnoses including orthopedic aftercare, fall with fracture, pain, dementia, osteoarthritis, hypertension, and GERD had no baseline plan of care in the medical record within 48 hours of admission. The Regional Corporate Nurse confirmed that a baseline plan of care had not been developed for this resident within the required timeframe. Another resident was admitted with multiple serious conditions, including displaced fracture of the anterior wall of the right acetabulum, Alzheimer’s disease, vascular dementia, peripheral vascular disease, multiple vertebral compression fractures, chronic embolism and thrombosis, fractures of the right pubis and left humerus, abdominal aortic aneurysm, gallbladder and bile duct disease, hyperosmolality and hypernatremia, and bilateral artificial hip joints. The hospital after-visit summary contained detailed instructions for heel wound care, pressure relief, positioning, and hip precautions, including not crossing legs and frequent repositioning. However, the resident’s care plan, last revised two days after admission, only addressed an identification wristband and risk for infection due to COVID-19 and did not include the heel wounds, skin assessment findings, hip precautions, or information on resident background, preferences, or personal care needs. Progress notes around admission were sparse and did not document these needs, and the Regional Nurse Consultant confirmed the absence of skin assessment documentation and hip precaution interventions in the baseline care plan and medical record. A third resident was admitted with cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease, and had impaired short- and long-term memory, oriented to self only. An initial wound grid documented admission with a Stage III sacral pressure ulcer, but the baseline care plan, with an observation date matching admission, was marked “not applicable” for wound care and contained no interventions related to pressure ulcers. A comprehensive care plan for pressure ulcers was not implemented until several days after admission. A “Meet and Greet” form was signed by Social Services, noted the resident was unable to sign, and lacked a representative’s signature or any description of what was discussed. There was no evidence that a summary of the baseline care plan was provided to the resident or a representative. The Regional Nurse Consultant confirmed that the initial clinical assessment and baseline care plan did not identify the pressure ulcer or required care, and that the nurse likely made an error due to multiple admissions that day. The facility’s care planning policy required a baseline care plan within 48 hours but did not address providing a summary of the baseline plan to residents or representatives.
Failure to Complete and Provide Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete a baseline care plan within 48 hours of admission and to provide a copy of that plan to the resident and/or representative, as required by facility policy. A resident admitted with multiple serious diagnoses, including COPD, sepsis, shock, lung cancer, heart failure, pneumonia, oxygen dependence, a recent fall, and nasal bone fracture, did not have a properly completed nursing admission assessment on the date of admission; the admitting nurse left the assessment, including the section documenting whether the resident or family received the Admission/Baseline Care Plan Summary, blank. The baseline care plan dated on the admission date contained only minimal information, listing the resident’s primary language and that allergies were “to be determined,” with the remainder of the form left blank. Further record review showed a second baseline care plan dated several days after admission that was mostly complete but still had some sections not filled out and lacked documentation that the resident or representative received a copy. This second plan was not developed within the required 48-hour timeframe. Additional care plans were initiated shortly after admission for a fall with injury, discharge planning, full code status, and potential for alteration in activities, but these did not meet the requirement for a comprehensive care plan in place of a baseline care plan within 48 hours. In an interview, the DON confirmed that nurses were not completing baseline care plans within 48 hours of admission and that there was no evidence of a timely baseline care plan for this resident, despite the facility’s written policy requiring an IDT-developed baseline plan of care within 48 hours and provision of a summary to the resident or representative.
Failure to Include Pain Management and Hearing Loss in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission that addressed pain management and hearing loss for one resident. The resident was admitted with multiple diagnoses, including discoid lupus erythematosus, depression, polyarthritis, cardiac arrhythmia, cervical disc disorder, a displaced fracture of the upper end of the left humerus, and rheumatic mitral stenosis. The resident’s MDS 3.0 assessment in progress indicated the resident was cognitively intact. Review of the baseline care plan showed that pain and hearing loss, including the use of a hearing aid, were not assessed or incorporated into the plan, despite the resident’s conditions and needs. Record review showed a hospital discharge order for Oxycodone immediate release 5 mg every four hours as needed, and a facility physician order for Oxycodone 5 mg every six hours as needed for pain related to the left humerus fracture. The resident reported experiencing excruciating pain and stated that the facility was unable to provide the Oxycodone for 36 hours. The resident also reported having hearing loss and wearing hearing aids. The MDS coordinator confirmed that the baseline care plan did not include pain or hearing loss and acknowledged that these should have been included. Facility policy on care planning required that the baseline care plan include the minimum healthcare information necessary to properly care for a resident.
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