Failure to Provide Baseline Care Plan Summaries Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide completed Baseline Care Plan (BCP) summaries to two of six sampled residents or their responsible parties within 48 hours of admission. During interviews and record reviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was found that there was no documentation indicating that the BCP summaries were given to the residents or their representatives. Specifically, for one resident, the DON could not locate a signed document or any evidence that the BCP summary was provided within the required timeframe. Similarly, for another resident, the ADON confirmed that although the BCP summary indicated participation in the review, there was no documentation or signature showing that a copy was provided to the resident or their representative within 48 hours. The facility's policy and procedure require that a baseline plan of care be developed and a summary provided to the resident and their representative within 48 hours of admission. This summary should include initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information based on the comprehensive care plan. The lack of documentation and signatures for the two residents demonstrates that the facility did not meet its own policy requirements for timely communication of the baseline care plan upon admission.