Failure to Provide Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to two residents or their representatives within 48 hours of admission, as required by facility policy and regulation. For one resident with diagnoses including heart failure and peripheral vascular disease, there was no documented evidence that the resident received a written summary of the baseline care plan, despite the resident stating they only received a medication list. The baseline care plan was completed, but no documentation showed that the summary was given to the resident or their representative. Similarly, another resident with cerebrovascular accident and heart failure, who had moderately impaired cognition, did not have documented evidence that their representative received the baseline care plan summary. The representative confirmed they had not received the summary. Interviews with facility staff revealed confusion regarding responsibility for providing and documenting the delivery of the baseline care plan summary, with staff members unable to recall issuing the summary or documenting its receipt. The facility's policy requires that the summary be provided in a language understandable to the resident or representative and that receipt be documented, but this was not done for the two residents in question.