Failure to Timely Initiate Care Plan After Transfer to Secured Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to timely implement a care plan for a resident who was moved to a secured memory care unit. Resident B, whose diagnoses included bipolar disorder and major depressive disorder, was transferred to the memory care unit as documented on a room change notice dated 7/18/25. Although the resident was residing on a secure unit due to dementia and exit-seeking behaviors, the clinical record did not contain a secured unit baseline care plan until 8/30/25, approximately two weeks after the room change. The care plan dated 8/30/25 indicated the resident resided on a secure unit due to dementia and exit seeking, but there was no earlier documentation of a secured unit baseline care plan in the record. During an interview, the Director of Nursing stated that the resident’s care plan for the secured unit should have been initiated at the time of the move. The Administrator provided a current policy document titled “Baseline Care Plan Assessment/Comprehensive Care Plans,” dated 3/23/21, which stated that the comprehensive care plan would expand on the resident’s risks, goals, and interventions using a person-centered plan of care with measurable goals and timetables, and that additional changes would be made to the comprehensive care plan based on the assessed needs of the resident. Despite this policy, the resident’s secured unit baseline care plan was not initiated until weeks after the transfer, resulting in noncompliance with care plan timeliness requirements.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.