Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to the residents or their representatives for two of the sampled residents. According to the facility's policy, a baseline care plan should be developed within 48 hours of a resident's admission and must include necessary healthcare information such as initial goals, physician orders, dietary orders, therapy services, social services, and PASARR recommendations if applicable. Additionally, the policy requires that a written summary of this baseline care plan be provided to the resident and/or their representative. For Resident 17, who was admitted on April 10, 2025, and Resident 64, who was admitted on January 22, 2025, the baseline care plans were developed on the respective dates of their admission. However, there was no evidence to support that the facility provided these residents or their representatives with a summary of the baseline care plan that included all the required components. This deficiency was confirmed during an interview with the Administrator on April 30, 2025.
Plan Of Correction
1. A comprehensive care plan review was completed with resident/responsible party 64 on 5/14/25. 2. Social Services will conduct a care plan review in a manner that can be fully understood with resident 17 by 5/31/2025. 3. The Director of Nursing/designee will educate all licensed nurses by 6/15/2025 on the requirement for all residents/responsible parties to receive a summary of their baseline care plan. 4. The Director of Nursing/designee will conduct an audit of 100% of residents admitted for 4 weeks, then 50% of residents for four weeks, and 25% of residents for 4 weeks to ensure they or their responsible parties have received a summary of their baseline care plan. The results of the audit will be reviewed by Director of Nursing/designee with the QAPI committee for further recommendation or action.