Failure to Provide Baseline Care Plan Summary to Resident
Penalty
Summary
The facility failed to provide a copy or summary of the baseline care plan to a resident and/or their representative within 48 hours of admission, as required by facility policy. The policy specifies that residents and/or their representatives must receive a summary of the baseline care plan, which includes initial goals, a summary of medications and dietary instructions, services and treatments to be administered, and any updated information from the comprehensive care plan. Record review and staff interviews confirmed that there was no documentation showing the baseline care plan was provided to the resident or their representative. The resident involved was admitted with multiple diagnoses, including thoracic vertebra fractures, ankylosing hyperostosis, and diabetes. The admission MDS assessment documented that the resident was cognitively intact. During an interview, the resident was unsure if he had received a copy of his care plan or had a meeting with staff about his care. The DON was unable to locate documentation that the baseline care plan had been provided to the resident or his representative.