Failure to Provide and Document Baseline Care Plans Upon Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan (BLCP), including a current list of medications, was provided to residents and/or their representatives and documented in the medical record within 48 hours of admission. For two residents reviewed, there was no evidence in the electronic health record (EHR) that the BLCP was present under the designated section, nor was there documentation that the BLCP had been provided to the resident or their representative. In one case, a resident with severely impaired cognition, as indicated by a BIMS score of 0, had a BLCP signed by the resident instead of the representative, contrary to facility expectations. The Director of Nursing (DON) confirmed that the required documentation and signatures were missing and that the BLCP was not properly scanned into the EHR. In another instance, a resident with dementia and a BIMS score of 2 had a BLCP with missing signatures from both the staff and the resident or representative, and there was no evidence that the BLCP or medication list had been provided. The DON and Regional Director of Clinical Operations (RDCO) verified that the required fields were incomplete and that the documentation process had not been followed as expected. These findings were based on medical record reviews and staff interviews conducted during the recertification survey.