Failure to Timely Develop and Review Baseline Care Plans with Residents
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for multiple residents, as required by policy. Several residents, including those with complex medical conditions such as congestive heart failure, diabetes, and end-stage renal disease, were admitted or readmitted to the facility, but their baseline care plans were either not completed within the required timeframe or lacked documentation that the plans were reviewed with the residents or their representatives. In some cases, baseline care plans were signed by staff several days after admission, and there was no evidence that residents received a copy of their care plan or participated in its review. Interviews with residents revealed that they did not recall receiving a plan of care or any related documentation, and some stated they had never received such information during multiple admissions. Record reviews confirmed the absence of documentation showing that baseline care plans were provided to or reviewed with the residents. Additionally, care plan meetings were held, but there was no documentation that the plans of care were discussed with the residents during these meetings. Staff interviews indicated a lack of clarity regarding the process and timing for completing and reviewing baseline care plans. Nursing managers and social workers acknowledged that baseline care plans were typically reviewed with residents at the first care conference, which often occurred after the 48-hour window. Documentation of resident receipt and review of the care plan was inconsistent or missing, and staff admitted that signatures from residents or their representatives were not routinely obtained or documented.