Failure to Provide Baseline Care Plan Summaries to Residents
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to two residents and/or their representatives within 48 hours of admission, as required by facility policy. The policy specifies that a baseline care plan must be developed within 48 hours and must include healthcare information necessary for proper care, such as initial goals based on admission, physician, dietary, and therapy orders, as well as social services and pre-admission screening information if applicable. The baseline care plan is to be updated as needed until the comprehensive care plan is developed, and a written summary must be given to the resident or their representative. Clinical record reviews showed that for two residents, the baseline care plans were developed, but there was no evidence that the required written summaries were provided to the residents or their representatives. This was confirmed by the Administrator during an interview, who acknowledged the absence of documentation showing that the summaries had been given as required.