F0655

D

Failure to Provide Baseline Care Plan Summary to Newly Admitted Resident

Fremont, California Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident received a summary of the baseline care plan within 48 hours of admission, as required. The resident was admitted with multiple significant diagnoses, including fractures of the left pubis, sacrum, and upper end of the left humerus, as well as dementia, difficulty in walking, and delirium. The admission record indicated the resident was self-responsible and identified a representative as the emergency contact. During review of the resident’s Interdisciplinary Care Conference (ICC) documentation, the Assistant Director of Nursing (ADON) stated she was unsure whether a summary of the baseline care plan had been provided to the resident or the representative, noting that the notes did not indicate this. The ICC form listed only facility staff as attendees, did not identify which representative participated, and left blank the section indicating whether a copy of the care plan summary was provided.

In a telephone interview, the resident’s representative reported that the admission agreement was only received on the day the resident was to be discharged and that the resident and family were unaware of the care and services to be provided at the facility. Review of the facility’s policy and procedure titled “Care Plan-Baseline” showed that it described the baseline care plan as including instructions for effective, person-centered care to be developed and implemented by the Interdisciplinary Team for each resident, but the policy did not specify when or how a summary of the baseline care plan should be provided to the resident or their representative. This lack of clear documentation and policy guidance contributed to the failure to provide the required baseline care plan summary to the resident or the representative.