Failure to Provide Baseline Care Plan and Medication Summary Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan (BLCP), including a list of medications, within 48 hours of admission. Review of the resident's medical record revealed that there was no evidence of a completed BLCP or documentation that the resident or their representative received a summary of the BLCP and medication list following admission. The process for completing and distributing the BLCP was described by the DON as being initiated by the admitting nurse, completed by any nurse within 48 hours, printed, signed by both the nurse and the resident or responsible party, and uploaded into the electronic medical record. However, for this resident, these steps were not completed or documented. Interviews with the DON confirmed that the responsibility for providing the BLCP summary and medication list to the resident or responsible party lies with the nursing staff, and that documentation should be present in a progress note. Despite these procedures, the DON was unable to provide evidence that the required documentation and distribution occurred for the resident in question. The absence of a completed BLCP and lack of documentation was verified by the DON during the survey.