Failure to Provide Written Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives for four residents reviewed. Record reviews for each resident showed no evidence that a written summary of the baseline care plan was given or documented as received by the resident or their representative. Interviews with staff, including the Assistant Director of Nursing, Director of Nursing, Interim Executive Director, and Social Services Director, confirmed that there was no documentation or signatures indicating that the baseline care plans had been provided or discussed with the residents or their representatives. The facility's policy required staff to review the baseline care plan and physician orders with the resident or representative, provide copies, and obtain signatures, but these steps were not documented as completed for the residents in question. Collateral contacts and residents interviewed did not recall receiving a written summary of the baseline care plan. Nursing progress notes and assessments for each resident lacked evidence of the required documentation. Staff acknowledged the importance of the baseline care plan in informing both staff and residents or representatives about the care to be provided, but confirmed that the process was not followed or documented for the affected residents.