Failure to Provide Baseline Care Plan Summary to Resident or Representative
Penalty
Summary
The facility failed to provide a resident and/or their representative with a summary of the baseline care plan, including physician's orders and medications, within 48 hours of admission as required by facility policy. The policy states that a baseline care plan must be developed within 48 hours to address the resident's immediate needs, and a summary of this plan, including initial goals, physician and dietary orders, therapy and social services, and PASARR recommendations if applicable, must be provided to the resident or their representative. In the case reviewed, a resident admitted with diagnoses including Parkinson's disease, high blood pressure, orthostatic hypotension, and high cholesterol did not have evidence in their clinical record that a copy of the baseline care plan, including physician orders and medications, was provided to them or their representative. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of documentation showing that the required information was given.