Failure to Provide Baseline Care Plan Summary Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete and provide a baseline care plan summary to a resident within 48 hours of admission, as required by policy. Medical record review showed that the resident, admitted with diagnoses including anoxic brain damage and post-traumatic seizures, did not receive a summary of the baseline care plan upon admission. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition and required staff assistance with activities of daily living (ADLs). Interviews with the resident and the Social Services Director confirmed that the resident was not provided with a summary of the baseline care plan and could not recall any meeting regarding his care. Facility policy requires that residents be informed of and participate in their care planning, with documentation of the discussion or viewing of the care plan. This process was not followed for the resident in question.