Failure to Provide Baseline Care Plan and Medication Summary Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan (BLCP), including a list of medications, within 48 hours of admission. Review of the resident's medical record showed no evidence that the BLCP or a summary of medications was given to the resident or their representative as required. The BLCP document for the resident was found, but the section for the resident or representative's signature and date, which would confirm receipt of the information, was left blank. Interviews with the DON and NHA confirmed that there was no documentation to show the resident received the BLCP and medication summary within the required timeframe. The deficiency was identified during a recertification/complaint survey, and the lack of proper documentation and resident acknowledgment led to the finding.