Failure to Provide Baseline Care Plan and Medication Summary to Residents/Representatives
Penalty
Summary
The facility failed to provide residents or their representatives with a copy of the baseline care plan, including a summary of admission medications, within 48 hours of admission as required. For one resident, the representative reported not receiving the baseline care plan or medication list, and record review confirmed that while a care plan was initiated and later marked as complete, it lacked both staff and representative signatures. There was no documentation to show that the representative had been given a copy of the care plan or medication summary. For another resident admitted for therapy after hospitalization, the baseline care plan was provided to the resident but not to the representative, as indicated by a blank signature area and lack of documentation in the medical record. The first care plan meeting with the family occurred 15 days after admission, which was the first time the level of care was communicated to them. Staff interviews revealed confusion about who was responsible for providing the baseline care plan to representatives, and no documentation was provided to confirm that the representative received the required information.