Failure to Provide Baseline Care Plan Summaries Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to residents and/or their representatives within 48 hours of admission, as required by facility policy. This deficiency was identified for five residents whose clinical records were reviewed. The records for these residents did not contain evidence that the required documentation was given to the residents or their representatives. The policy in place specified that a written summary of the baseline care plan should be provided, but this was not reflected in the clinical records for the affected individuals. The residents involved had various medical conditions, including anxiety, hypertension, dementia, diabetes mellitus, gout, polyneuropathy, obstructive sleep apnea, chronic obstructive pulmonary disease, cellulitis, diverticulitis, and radiculopathy. During an interview, the DON confirmed that the clinical records for these residents lacked documentation showing that the written summaries were provided upon admission. The deficiency was cited under 28 Pa. Code 211.10(c)(d) and 28 Pa. Code 201.18 (b)(1).