Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written copy of the baseline care plan to a resident and/or their responsible party within 48 hours of admission, as required by their policy. This deficiency was identified for one resident, who was admitted with multiple diagnoses including diabetes mellitus, metabolic encephalopathy, obstructive and reflux uropathy, and dementia. The resident's care plan was completed within the required timeframe, addressing various risks and needs, but the written summary was not provided to the resident or their family member. Interviews with facility staff revealed that the Social Services Director did not document the provision of the baseline care plan to residents or their representatives. The Director of Nursing confirmed the expectation that a written summary should be given within 48 hours of admission. The facility's policy mandates the development of a baseline care plan within 48 hours and the provision of a written summary to the resident and/or their representative, which was not adhered to in this case.
Plan Of Correction
A written summary of the baseline care plan was provided to R203 and [R] representative. All residents have the ability to be affected by this practice. The Administrator inserviced the Interdisciplinary Team members to provide a written summary of the baseline care plan to the resident or resident representative within 48 hours of admission to the facility. The MDS Coordinator will audit 5 admissions per month to ensure a written summary of the baseline care plan was provided to the resident or resident representative. Results of these audits will be provided to the Administrator on a monthly basis. The MDS Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.