Failure to Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to implement a process to ensure that a baseline care plan was developed for every resident within 48 hours of admission and that a summary of this care plan was provided to the resident and their representative. Clinical record reviews for seven residents showed no evidence that either the residents or their representatives received a baseline care plan. Staff interviews revealed that the MDS coordinator completed baseline care plans in the computer system but did not print, provide, or review them with residents or their families. The MDS coordinator also indicated a lack of awareness regarding the requirement to provide the baseline care plan within 48 hours of admission. The facility's policy stated that a baseline plan of care should be developed within 48 hours of admission and that a summary should be provided to the resident and their representative. However, during interviews and document reviews, it was confirmed that this process was not consistently followed. The DON was unable to find evidence that baseline care plans had been provided to residents, and the issue was discussed with facility leadership during the survey.