Failure to Provide Baseline Care Plan Summary to Resident's Representative
Penalty
Summary
Facility staff failed to provide a baseline care plan summary to the resident's representative within 48 hours of admission for one resident. The resident was admitted with multiple complex diagnoses, including Parkinson's disease, sepsis, urinary tract infection, pressure ulcer, respiratory failure, and a history of hip fracture, and was assessed as having severely impaired cognitive skills. The admission assessment included a baseline care plan addressing key care areas such as catheter care, constipation prevention, hospice services, diet, pressure ulcer care, fall prevention, and assistance with activities of daily living. Despite the creation of the baseline care plan, there was no documentation in the clinical record that the plan was reviewed with the resident's representative or that a summary or copy of the plan was provided. The relevant sections of the admission assessment regarding completion and review of the baseline care plan, as well as provision of the plan summary and medications, were not completed. Staff interviews confirmed that the baseline care plan should have been reviewed and provided to the family, and that this could be done through the electronic health record, but there was no evidence this occurred.