Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to three residents or their representatives within 48 hours of admission, as required by their policy. The policy, dated 2/15/24, mandates that a copy of the baseline care plan be given at the new admission care plan meeting, typically held within 48 hours of admission. This includes a summary of the resident's medications, dietary instructions, and any services and treatments to be administered. However, the clinical records for three residents lacked evidence of this documentation. Resident R8, admitted with diagnoses including heart failure, atrial fibrillation, and anxiety, did not receive the required documentation. Similarly, Resident R15, with dementia, osteoarthritis, and hypothyroidism, and Resident R60, with hypertension, hypothyroidism, and congestive heart failure, also did not receive the necessary written summaries. The Nursing Home Administrator confirmed the absence of these documents in the clinical records during an interview, indicating a failure to comply with the facility's care plan policy.
Plan Of Correction
1) Baseline Care Plan to be provided to R60, R15, and R8 with completion of Admission Care Plan assessment in PointClick Care. 2) Admission Care Plan assessment created in PointClick Care for nursing staff to complete at time of admission with proof that baseline care plan was provided. 3) Provide training to LPN's/RNs on new assessment and importance of completing the required documentation. 4) The Director of Nursing/designee will audit all new admissions/recent admissions for completion of assessment; 1x weekly for 3 weeks then 1x monthly x2. 5) Results of the audits to be reviewed at quarterly QAPI meeting.