Failure to Provide Written Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide residents and their representatives with a written summary of the baseline care plan within 48 hours of admission, as required by facility policy. For two residents reviewed, both with complex medical conditions and cognitive impairments, there was documentation of baseline care plans being developed and family conferences being held to discuss care. However, there was no evidence in the medical records, family conference forms, or nursing progress notes that the residents or their representatives received a written summary of these baseline care plans. Interviews with the MDS Coordinator confirmed that neither resident nor their representatives were given the required written summaries. The facility's policy, revised in March 2022, specifies that such summaries must be provided in a language understandable to the resident or representative. Despite this policy, the documentation and staff interviews verified that this step was not completed for the two residents reviewed.
Plan Of Correction
All residents have the ability to be affected. All baseline care plans reviewed by DON, MDS/designee to ensure they are in place on 5/22/25 and residents received a copy. Admin provided MDS Coordinator education on baseline care plan policy and importance of timely patient review and acknowledgment immediately on 5/21/25. DON provided all nursing staff education on baseline care plan policy and importance of timely patient review and acknowledgment on 5/22/25. DON/designee to audit 3 new admissions baseline care weekly to ensure timely receipt of baseline care plans for 4 weeks. Results to be reviewed in QAPI.