Failure to Complete Baseline Care Plan and Provide Medication Summary Upon Admission
Penalty
Summary
The facility failed to complete a baseline care plan (BLCP) within 48 hours of admission for one resident, as required. Review of the medical record for this resident showed no evidence that a BLCP was created or documented. The BLCP is intended to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. Additionally, there was no documentation that a summary of the BLCP or a current medication list was provided to the resident or their representative. Interviews with the Director of Nursing (DON) revealed uncertainty regarding the required timeframe for BLCP completion, with the DON incorrectly stating it was within 72 hours instead of 48. The DON also indicated that the admitting nurse initiates the BLCP and that each discipline contributes, but was unable to locate the BLCP in the resident's record or provide evidence that a copy was given to the resident or representative. Ultimately, the DON confirmed that a BLCP was never completed for the resident in question.