Failure to Develop Complete Baseline Care Plans and Provide Written Summaries
Penalty
Summary
The facility failed to develop baseline care plans (BCPs) for three residents upon admission, as required. For each resident, the BCPs were missing essential components, including initial goals, physician orders, and current dietary orders. Additionally, there was no documentation that a written summary of the care plan was provided to the residents or their representatives after completion. These omissions were identified through interviews and record reviews. The residents involved had significant medical and cognitive needs, including diagnoses such as autism, intellectual disability, epilepsy, cerebral palsy, osteomyelitis, and diabetes. Assessments showed that these residents required varying levels of assistance with activities of daily living (ADLs) and mobility. Staff interviews confirmed a lack of awareness regarding the required components for BCPs, and the Director of Nursing Services acknowledged not being aware of the need to include initial goals, physician, and dietary orders in the care plans.