Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a process to ensure that baseline care plans were provided to residents and their representatives within 48 hours of admission. Specifically, for two residents with dementia, there was no evidence in the medical records that a baseline care plan, including initial goals, physician orders, therapy, dietary, and social services, was reviewed or given to the residents or their representatives. Interviews with the residents' representatives confirmed that they were not given a baseline care plan or had a meeting with facility staff to discuss the plan. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that the facility's current process involved discussing goals with the resident and family within 72 hours of admission, but nothing was provided in writing to the resident or their representative. The DON confirmed that there was no documentation in the medical record showing that the baseline care plans were reviewed and provided to the residents or their representatives.