Failure to Provide Baseline Care Plans to Residents and Representatives Upon Admission
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received a copy of the baseline care plan upon admission, as required prior to the completion of the comprehensive care plan. This deficiency was identified for five residents, each with complex medical histories, whose records lacked documentation that the baseline care plan was provided or discussed at the time of admission. The absence of this documentation was confirmed through both record review and staff interviews. For example, one resident with diagnoses including alcoholic hepatic failure, hepatic encephalopathy, diabetes, anemia, and thrombocytopenia was admitted without evidence that a baseline care plan was given to the resident or their representative. The Social Services Director (SSD) acknowledged that she had not provided the baseline care plan at admission and only met with the representative months later. Similarly, another resident with hypertension, gastroesophageal reflux disease, Charcot's joint, repeated falls, and cellulitis was admitted without documentation of receiving a baseline care plan, which the SSD confirmed had not been provided or discussed. Additional residents with significant health issues such as repeated falls, chronic viral hepatitis C, fractures, stroke sequelae, dysphagia, malnutrition, respiratory failure, heart failure, kidney failure, and cancer were also admitted without documented provision of the baseline care plan. The SSD indicated that she had only recently been educated on the requirement to provide baseline care plans at admission, and prior to this, baseline care plans were not consistently completed or distributed. Facility policy required that residents and/or their representatives receive a summary of the baseline care plan prior to the comprehensive care plan, but this was not followed for the residents reviewed.