Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to Resident R164 and their representative, which is a requirement under §483.21(a)(3). The baseline care plan should have included initial goals based on admission orders, physician orders, therapy services, and social services. Resident R164 was admitted with diagnoses including a progressive neurological condition, cerebrovascular accident (stroke), and Parkinson's disease. Despite these conditions, there was no documented evidence that the resident or their representative received the necessary written summary of the baseline care plan. Interviews with Resident R164 and their family revealed that they were unaware if all medications were being administered, indicating a lack of communication and documentation. The Social Service Director confirmed that a baseline care plan meeting was not conducted, and a written summary was not provided to the resident or their representative. This oversight was identified during a review of clinical records and interviews, highlighting a deficiency in meeting the regulatory requirements for baseline care planning.
Plan Of Correction
1) Resident R164 and their resident representative was provided with a written summary of the baseline care plan. 2) Current residents admitted in the past 30 days will be audited to ensure compliance with baseline care plans. Any variances will be addressed. 3) Administrator / designee will educate social services staff on baseline care plan policy. 4) Social Service Director / designee will conduct audits of new admissions to ensure compliance with baseline care plans policy. Audits will be completed weekly x 3, then monthly x 2 or until compliance is met. Variances will be addressed and reported to The QAA Committee.