Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to ensure a written summary of the baseline care plan was provided to two residents within the required timeframe. Resident #390, a male with diagnoses including right ankle osteomyelitis and asthma, was admitted to the facility and did not receive a written summary of his initial care plan. The Baseline Care Plan Assessment for this resident was completed and signed by staff, but there was no signature from the resident or his representative, and no documentation was found to confirm that a copy was provided to the resident. The Assistant Director of Nursing (ADON) acknowledged the oversight and could not confirm if the resident received the required documentation. Resident #546, admitted with diagnoses including aftercare following surgery on the digestive system, also did not receive a timely written summary of her baseline care plan. Although the resident was admitted on a Friday, the baseline care plan was not completed and signed until several days later, beyond the 48-hour requirement. The ADON admitted that the baseline care plan should have been completed and signed within the required timeframe to ensure the resident was informed of her care plan. The facility's policy mandates that a baseline care plan be developed and provided to the resident within 48 hours of admission, which was not adhered to in these cases.
Plan Of Correction
F655 Baseline Care Plan Resident #390 baseline care plan was completed and reviewed with the resident on Resident #546 baseline care plan was completed and reviewed with the resident on An audit of current residents records for the baseline care plans was completed by nursing management on Baseline care plans were completed as appropriate. The licensed staff will be in-serviced by the DON and/or designee regarding providing a written summary of the baseline care plan within the required time frame. Newly admitted resident baseline care plan will be reviewed and updated with 48-hour time frame. Nursing staff will review baseline care plan completion date with resident daily to ensure completion within 48-hours. Weekly audits of all new admissions will be completed by the DON and/or designee for three months then until significant compliance has been met to ensure the baseline care plan has been completed within the required time frame. The results of the audits will be reviewed and discussed at the monthly QAPE committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.