Failure to Provide Baseline Care Plan and Medication List to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and medication list to residents or their responsible parties within the required timeframe for two out of four residents reviewed. One resident with severe cognitive impairment was admitted and neither the resident nor the responsible party received documentation regarding the care plan or medications. The responsible party, who visited almost daily, confirmed not receiving any information about the plan of care or medications. The electronic health record also lacked documentation of this requirement being met. Similarly, another resident who was cognitively intact did not receive a written summary of the baseline care plan or medication list after admission. The resident confirmed not receiving any documentation about the plan of care or medications. In both cases, the Social Worker, who was responsible for providing these documents, acknowledged falling behind in the process. The DON and Administrator were unaware that the required information had not been provided to the residents or their responsible parties.