Failure to Complete Baseline Pain Management Care Plan for Hospice Resident
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that addressed a hospice resident’s significant pain management needs. The resident, a middle‑aged female with metastatic malignant neoplasms of the right breast, liver, intrahepatic bile ducts, and bone, as well as chronic pain and depression, was admitted for respite care and then remained at the facility. Record review showed that the resident’s baseline care plan had been started but not completed, and it contained no information about her pain or hospice services. The facility’s own policy required person‑centered baseline care plans to be developed and implemented within 48 hours of admission, including measurable objectives to meet the resident’s medical, nursing, mental, and psychosocial needs. Clinical documentation and observations showed that the resident had ongoing, severe pain that was not effectively addressed in a care plan. An initial pain assessment documented non‑verbal indicators of pain, including occasional labored breathing, repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, tense body language, and a pain score of 6 with generalized body pain, while the resident’s acceptable pain level was recorded as 0. Progress notes from admission described the resident as confused, disoriented, crying, restless, and unable to control her body, with hospice already involved and the facility physician agreeing to continue hospice orders. Despite this, there was no completed baseline care plan outlining pain management interventions or coordination with hospice services. Surveyor observations and staff and family interviews further demonstrated that the resident exhibited persistent signs of severe pain over multiple days without a guiding baseline care plan. On multiple observations, the resident was seen thrashing, writhing, moaning, crying, grimacing, and screaming during movement and incontinent care, with symptoms worsening on touch or repositioning. Nursing staff reported that the resident “was always crying,” that morphine given as needed every 1–2 hours did not appear effective, and that she would only sleep briefly before waking and resuming moaning and crying. CNAs described frequent crying, screaming, restlessness, and grimacing, and reported uncertainty about the source of pain and the effectiveness or timing of medications. Family members stated the resident had been in pain during each visit, believed her pain was not being managed, and reported that staff often only glanced into the room rather than performing full assessments. Multiple nurses, ADONs, the DON, and the Administrator all acknowledged in interviews that pain should have been included in the baseline care plan, that the resident’s baseline care plan was not completed, and that its absence meant staff did not have a defined plan of care or interventions for managing the resident’s pain. The facility’s leadership and nursing staff confirmed that the baseline care plan for this resident was not triggered or completed when she was admitted for respite care and that pain management was not care planned despite her known metastatic cancer and documented severe pain. Staff interviews consistently indicated that baseline care plans are supposed to be completed on admission by the admitting nurse, that pain must be included when present, and that these plans guide staff on how to care for residents, including when and how to address pain. In this case, the lack of a completed baseline care plan with pain interventions and hospice coordination resulted in staff relying on PRN medications without a structured, person‑centered plan, while the resident continued to display ongoing, excruciating pain over the period reviewed.
Penalty
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A resident admitted with CHF and moderate cognitive impairment did not receive a baseline care plan within 48 hours of admission to address CHF-related needs. The MDS nurse, responsible for initiating diagnosis-related care plans, confirmed that no CHF-specific baseline care plan existed, even though the resident required assistance with multiple ADLs. The DON acknowledged that baseline care plans are important on admission, and facility policy requires timely development of a baseline care plan including goals, physician and dietary orders, and interventions based on admission information, but these requirements were not followed for this resident’s CHF diagnosis.
A resident admitted with CKD stage 5 on dialysis, neuromuscular bladder dysfunction, and anxiety did not have a baseline care plan developed within 48 hours of admission, as confirmed by record review and staff interviews. The Interim DON acknowledged that the baseline care plan was only started several days after admission and stated that her expectation was for an RN to complete it within the first 48 hours. The Administrator similarly reported that nursing was expected to complete the baseline care plan upon admission and recognized that failure to do so could affect quality of care by leaving staff without needed care instructions. When surveyors requested the facility’s baseline care plan policy, no policy was provided before exit.
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.
The facility failed to complete and individualize baseline care plans within 48 hours of admission for several newly admitted residents. Some residents had no baseline care plan in the EMR, while others had plans that were signed but undated or missing key information such as required assistance levels for ADLs, transfer methods, diet orders, use of assistive devices, and ordered rehab therapies. An LPN reported that nurses initiate baseline care plans at admission, and the MDS/RN acknowledged that staff may not know how to provide care if plans are not resident-specific. The regional nurse consultant confirmed that some residents lacked individualized baseline care plans and that the facility likely did not have signed baseline care plans or documentation that copies were provided, despite a policy requiring completion of a comprehensive baseline care plan within 48 hours including physician, dietary, therapy, and social service information.
Failure to complete a baseline care plan within 48 hours of admission for a resident with pneumonia, CHF, CKD, COPD, prostate cancer, osteoarthritis, and weakness. The resident had a BIMS score of 00, required extensive ADL assistance, and had multiple allergies listed in physician orders, but no baseline care plan was found in the record. The DON stated the 48-hour care plan should have been completed on admission and that it was not done because the Nursing admission assessment was incomplete.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
Failure to Develop Baseline Care Plan for CHF on Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address a resident’s primary admitting diagnosis of congestive heart failure (CHF). The resident was admitted with CHF and had an MDS assessment showing moderately impaired cognitive skills for daily decision-making and functional needs including assistance with oral hygiene, eating, personal hygiene, and dependence for toileting hygiene and bathing. Review of the admission record and baseline care plans showed no documented baseline care plan specific to CHF, despite CHF being the primary admitting diagnosis. The MDS nurse, who stated that diagnosis-related care plans are initiated by the MDS department, confirmed that there was no baseline care plan for CHF and acknowledged that one should have been in place. The DON stated that baseline care plans are important to be initiated on admission to ensure nursing staff provide appropriate care based on admitting diagnoses and to allow staff to evaluate and revise interventions as needed. The facility’s own policy titled “Baseline Care Plan,” last reviewed on 4/24/2025, requires that a baseline care plan be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. The policy also specifies that the admitting or supervising nurse must gather information from the admission assessment, hospital transfer information, physician orders, and discussions with the resident or representative to establish initial goals and interventions addressing current needs and health and safety concerns. Despite these requirements, no baseline care plan addressing the resident’s CHF was developed within the required timeframe.
Failure to Complete Timely Baseline Care Plan After Admission
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that a male resident, identified as Resident #80, was admitted on 4/27/2026 with diagnoses including chronic kidney disease stage 5 requiring dialysis, dependence on renal dialysis, neuromuscular dysfunction of the bladder, and anxiety. Review of the electronic clinical record on 4/30/2026 revealed that no initial baseline care plan had been developed within the required 48-hour timeframe following his admission. During interviews, the Interim DON confirmed on 4/30/2026 that a baseline care plan had not been completed within 48 hours and stated she had only started the baseline care plan that day. She reported that her expectation was that baseline care plans be completed within the first 48 hours after admission by an RN and acknowledged that not completing the baseline care plan could result in staff not knowing how to care for the resident. In a separate interview, the Administrator stated her expectation that nursing complete the baseline care plan upon admission and acknowledged that failure to complete it timely could affect residents’ quality of care by staff not knowing how to care for them. When surveyors requested the facility’s baseline care plan policy from the DON on 4/30/2026, no policy was provided prior to exit.
Failure to Include ADL Needs in Baseline Care Plan
Penalty
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.
Failure to Complete and Individualize Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and complete individualized baseline care plans within 48 hours of admission that contained the minimum healthcare information necessary to properly care for multiple residents, and to ensure these plans were reviewed with and offered to residents or their representatives. Record review showed that one resident admitted on 9/25/25 had a signed baseline care plan that lacked documentation of required assistance levels for transfers, bed mobility, bathing, dressing, toileting, eating, and did not include the physician-ordered diet. Another resident’s baseline care plan, last revised on 1/9/26, was signed but undated and similarly omitted the level of assistance needed for transfers, bed mobility, bathing, dressing, toileting, and eating. A third resident admitted on a specified date had no baseline care plan at all, and a fourth resident’s baseline care plan, uploaded on 12/19/25 and signed but undated, did not indicate how the resident transferred, walked, whether assistive devices were required, or the amount of assistance needed for dressing or toileting. Additional record reviews revealed that another resident admitted on a specified date had no baseline care plan in the EMR, and a further resident’s baseline care plan dated 4/5/26 did not specify how she transferred between surfaces, her diet, or the specific physician-ordered rehabilitation therapies. Interviews with the regional nurse consultant confirmed that two residents did not have individualized baseline care plans completed and that the facility likely did not have signed baseline care plans or documentation that copies were provided to residents or their representatives. An LPN stated that nurses initiate baseline care plans during admission and that all nurses and leadership can update them, and the MDS/RN acknowledged that staff may not know how to provide care if care plans are not resident-specific and completed, and confirmed that two residents’ baseline care plans, although reviewed with their representatives, were not personalized with specific care information. Policy review showed that the facility’s care plan policy required baseline care plans to be started on the first day of admission, completed within 48 hours, and to include minimum healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, which was not consistently done.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #92. The resident was an [AGE] year-old male admitted with diagnoses including pneumonia, chronic congestive heart failure, chronic kidney disease, COPD, malignant neoplasm of the prostate, osteoarthritis, and weakness. His physician orders listed allergies to aluminum hydroxide, calcium carbonate, cefdinir, magnesium carbonate, magnesium hydroxide, and Protonix. An admission MDS showed a BIMS score of 00, indicating difficulty with short-term memory, orientation, and attention, and that he required extensive assistance with most activities of daily living. The medical record showed that Resident #92 did not have a baseline care plan. The resident was discharged from the facility on 02/14/2026. During interview, the DON stated that a 48-hour care plan should have been completed when the charge nurse admitted the resident, and that the Nursing admission Assessment was intended to identify concerns and trigger the baseline care plan. The DON said the baseline care plan was not completed because the Nursing admission Assessment was incomplete, and she was new to the facility and unsure who was responsible for ensuring baseline care plans were completed. The facility policy stated that the baseline care plan was to be developed within 48 hours of admission and include minimum healthcare information such as initial goals based on admission orders, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
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