Failure to Provide Baseline Care Plan to Resident's Representative Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide a baseline care plan to a resident's representative within 48 hours of admission, as required. Upon review of the medical record and interviews, it was found that the resident was admitted from the hospital for rehabilitation services, but there was no documentation that a baseline care plan was reviewed or given to the resident's representative. The baseline care plan should have included initial goals, physician orders, therapy services, dietary services, and social services, as well as a list of admission medications. Interviews with the resident's representative confirmed that they were not given a baseline care plan or included in a meeting to discuss the resident's admission within the first 48 hours. The DON stated that the process is to assess the resident and generate a baseline care plan, which is then reviewed with the resident or their representative, but confirmed that this did not occur for this admission. The resident also expressed a desire for their representative to have been involved in the care planning meeting.