Failure to Provide and Document Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop and implement baseline care plans and/or provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission for seven out of fifty-five sampled residents. In several cases, baseline care plans were either not created within the required timeframe or, when created, were not reviewed with the resident or their representative, nor was a written summary provided as required by facility policy. Documentation often lacked signatures or other evidence that the care plan had been reviewed or received by the resident or their representative. Multiple residents with complex medical histories, including conditions such as bipolar disorder, seizures, chronic kidney disease, atrial fibrillation, diabetes, and Parkinson's disease, were affected by these deficiencies. For example, one resident with cognitive impairment and another who was cognitively intact both reported not receiving or reviewing their baseline care plans. In some cases, family members expressed concerns about care practices, such as toileting, and reported not being involved in care planning discussions or provided with care plan documentation. Interviews with staff revealed confusion and inconsistency regarding who was responsible for providing and reviewing baseline care plans with residents and their representatives. Some staff believed it was the responsibility of the nurse on the hall, while others assumed the social worker handled it. Facility policy clearly stated that a supervising nurse or MDS nurse/designee was responsible for providing the written summary and obtaining signatures, but this process was not consistently followed, resulting in a lack of documentation and communication with residents and their representatives.