Failure to Complete and Distribute Baseline Care Plans Within Required Timeframe
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided with summaries of their baseline care plans (BLCP), including a list of medications, and did not complete the BLCP within the required 48-hour timeframe following admission. Specifically, for two residents reviewed, there was no evidence in the medical records that a BLCP summary or medication list was provided within the mandated period. In one case, the section of the medical record designated for documenting that a copy was given to the resident or representative was left unchecked, and the assessment was completed after the 48-hour window. In the other case, the BLCP was completed after the required timeframe, and the responsible staff member confirmed the delay without providing a reason. Interviews with facility staff, including the DON and the Regional Director of Social Services, revealed inconsistencies in the process and responsibility for completing and distributing the BLCP. The staff acknowledged that the process was not followed as required, and there was a lack of documentation to support that residents or their representatives received the necessary information in a timely manner. These findings were based on a review of medical records and staff interviews during the recertification/complaint survey.