Failure to Provide Care Plans to Resident and Family Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide the baseline and comprehensive care plans to a resident or the resident's family within forty-eight hours of admission, as required to promote continuity of care and communication with staff. The resident in question had multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, depression, and bipolar disorder, and required significant assistance with activities of daily living. The baseline care plan was developed and included interventions such as toileting every two hours, incontinent care, medication administration, and behavioral monitoring. However, a review of the clinical record from the time the baseline care plan was developed through two months later did not show documentation that a meeting was held with the resident or family to discuss the care plan, nor that a copy of the care plans was provided to them until a meeting occurred two months after admission. Interviews with facility staff, including the Director of Social Services and the therapy department, confirmed there was no record of an earlier meeting. Facility policies reviewed indicated residents have the right to participate in their own care planning and treatment, but this was not documented as occurring within the required timeframe.