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 two residents, R110 and R112, or their representatives. Resident R110 was admitted on 9/6/24 with diagnoses including dementia and chronic obstructive pulmonary disease. The clinical record for R110 did not contain evidence that a written summary of the baseline care plan and order summary was provided to the resident or their representative. Similarly, Resident R112, admitted on 9/17/24 with diagnoses of dementia, hypertension, and hyperlipidemia, also lacked documentation in their clinical record indicating that a written summary of the baseline care plan and order summary was provided. The Director of Nursing confirmed during an interview that the clinical records for both residents did not include evidence of the required documentation being provided upon admission.
Plan Of Correction
This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Edinboro Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Edinboro Manor's credible allegation of compliance. The facility will ensure that all new admissions are provided with baseline care plans and order summaries. R110's representatives were provided with a written summary of their current care plan and order summary. R112's representatives were provided with a written summary of their current care plan and order summary. The DON/Nursing designee will audit all admissions within the last 30 days to ensure residents receive a written summary of their baseline care plan and order summaries. The Administrator and/or designee will provide education to the Resident Services Coordinator regarding the importance of providing residents with a written summary of their baseline care plan and order summaries during care conferences. Audits of all new admissions will be conducted 3 times a week for 4 weeks. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.