Failure to Initiate and Communicate Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to initiate a baseline care plan and provide a written summary of the baseline care plan and order summary to residents and/or their representatives for four out of thirteen residents reviewed. Specifically, clinical records for these residents did not contain evidence that a baseline care plan was created within 48 hours of admission, nor that a summary of the care plan and physician orders was provided to the resident or their representative, as required. This deficiency was confirmed through clinical record review and staff interviews, and no facility policy regarding this process was provided. The residents affected had significant medical conditions, including dementia with severe cognitive impairment, protein-calorie malnutrition, pneumonia, malignant neoplasm of the prostate, sleep apnea, end stage renal disease, high blood pressure, kidney failure, diabetes, and amputation. Despite these complex needs, there was no documentation that their immediate care needs were assessed and planned for upon admission, nor that this information was communicated to them or their representatives.