Failure to Initiate and Provide Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to initiate baseline care plans within 48 hours of admission and to provide written summaries of those plans, including order summaries, to three residents and/or their representatives. Facility policy dated 11/01/25 required development and implementation of a baseline care plan for each resident within 48 hours of admission, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations when applicable. The policy also required that a written summary of the baseline care plan be provided to the resident and/or representative in an understandable language, including initial goals, a summary of medications and dietary instructions, and any services and treatments to be administered by facility personnel. Clinical record review showed that one resident admitted with chronic kidney disease, hemiplegia/hemiparesis following cerebral infarction, diabetes mellitus, and COPD did not have evidence of an initiated baseline care plan or a provided written summary. A second resident admitted with morbid obesity, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea similarly lacked documentation of a baseline care plan and provision of the required written summary including physician orders, medications, dietary orders, and therapy services. A third resident admitted with severe protein-calorie malnutrition, dysphagia, gastroparesis, and diverticulitis also had no evidence of a baseline care plan or written summary being initiated or provided. During interview, the Nursing Home Administrator confirmed there was no evidence that baseline care plans or copies including physician orders, medications, dietary orders, and therapy services were initiated or provided for these three residents and/or their representatives, in violation of 28 Pa. Code 211.10(c) and 211.12(d)(1)(3)(5).
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