Failure to Provide Baseline Care Plan to Responsible Party
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to the responsible party for one resident who was admitted and later readmitted with a diagnosis that included non-traumatic intracerebral hemorrhage and was noted to be severely cognitively impaired. Documentation showed that a baseline care plan was completed by a unit manager within the required timeframe, but there was no evidence in the medical record that a copy of this care plan was given to the resident or the responsible party, despite the resident having a family member listed as the responsible party. Multiple attempts to interview the responsible party were unsuccessful, and staff interviews revealed that the admitting nurse did not complete or provide a summary of the baseline care plan. Further interviews with facility leadership, including another unit manager and the DON, confirmed that the expectation was for the baseline care plan to be developed and provided to the resident or responsible party within 48 hours of admission. However, the DON could not confirm that the summary was ever provided in this case. The administrator also stated that it was expected for the resident and/or responsible party to receive a written summary of the baseline care plan within 48 hours, but this did not occur for the resident in question.