Failure to Provide Baseline Care Plan Summary Upon Admission
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and/or the resident's representative within the required timeframe after admission. The resident, who was admitted with an infection and inflammatory reaction due to an internal joint prosthesis, was cognitively intact and receiving pain management, wound care, oxygen, and therapy services. Documentation in the electronic medical record did not show evidence that a baseline care plan was given to the resident. Interviews with the resident and staff confirmed that the resident did not recall receiving a care plan or participating in a care conference, and staff were unable to provide documentation that the care conference or baseline care plan had been completed or provided. Facility policy required that a baseline plan of care be developed within forty-eight hours of admission and that a written summary be provided to the resident or representative, with documentation of this provision in the medical record. However, staff interviews revealed that the initial care conference, where the baseline care plan is typically provided, may not have occurred within the required timeframe, and no documentation could be produced to show that the baseline care plan summary was given to the resident. This resulted in a failure to meet the resident's immediate needs as outlined by facility policy and regulatory requirements.