Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and document baseline care plans and provide written summaries to residents or their representatives within 48 hours of admission for four recently admitted residents. Record reviews showed that baseline care plans were either incomplete, missing required sections such as active diagnoses, staff and resident signatures, or not documented as being reviewed with the resident or their representative. In several cases, there was no evidence that a copy of the baseline care plan was offered or provided to the resident or their representative. Interviews with the residents revealed that they did not recall reviewing their care plans or being offered copies within the required timeframe. Specific observations included residents with moderate cognitive impairment, use of medical devices such as CPAP machines and equalizer boots, and recent hospitalizations. The facility's policy required an interim plan of care to be developed within 24 hours of admission but did not specify that the plan must be reviewed with the resident or representative within 48 hours. The DON confirmed that several baseline care plans were incomplete and lacked documentation of review or provision to the residents or their representatives.