Failure to Provide Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan and order summary to three residents and/or their representatives within 48 hours of admission, as required by facility policy. The policy specifies that residents and their representatives must receive a summary including initial goals, medications, dietary instructions, services and treatments, and any updates based on the comprehensive care plan. Review of clinical records for three residents revealed no evidence that these written summaries were provided following their admissions. The residents involved had complex medical histories, including conditions such as sacrococcygeal disorders, end stage renal disease, hemiplegia and hemiparesis following cerebral infarction, diabetes mellitus, dementia, atrial fibrillation, orthostatic hypotension, and nasal bone fracture. Staff interviews confirmed the absence of documentation showing that the required written summaries were given to the residents or their representatives, resulting in noncompliance with state regulations regarding resident care plans and nursing services.