Failure to Provide Baseline Care Plan and Order Summary Upon Admission
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to a resident and/or their representative within 48 hours of admission. Review of the clinical record for a resident admitted with diagnoses including anxiety, bipolar disorder, and hypertension showed no evidence that these documents were given as required. This was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record lacked documentation of the written summary of the baseline care plan and order summary being provided to the resident or their representative upon admission.