Failure to Develop Timely Baseline Care Plans and Provide Written Summaries to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure baseline care plans were developed within required timeframes and that written summaries of these plans were reviewed with and provided to residents or their representatives. Facility policy required an interim/baseline care plan to be developed and implemented within 24 hours of admission, using information from the admission assessment, hospital transfer documents, physician orders, and discussions with the resident and/or representative, with initial goals reflecting the resident’s stated goals and objectives. The policy also required that a comprehensive care plan be developed within 7 days after completion of the comprehensive MDS assessment, with participation from the resident and/or representative to the extent practicable. Despite these policies, records showed that baseline care plans were either not timely or did not document resident/representative participation or receipt of a written summary. For one resident admitted from the hospital with diagnoses including stroke, difficulty swallowing after stroke, and circulatory system surgery, the interim (baseline) care plan contained no documentation that the resident or resident representative participated in or reviewed the baseline care plan. The comprehensive admission MDS assessment was completed, and the comprehensive care plan was developed with a focus on the resident’s need for long-term care due to decreased mobility and weakness requiring assistance with transfers, toileting, and ADLs. However, the first care plan meeting with the resident/representative occurred two days after completion of the comprehensive care plan, which did not allow participation in the development of either the baseline or comprehensive care plan. The medical record contained no documentation that a written summary of the baseline care plan was provided to the resident or representative. For another resident admitted with Parkinson’s disease, visual hallucinations, and a urinary tract infection, progress notes documented that the resident arrived able to walk with a walker, with a bent neck posture and shakiness due to Parkinson’s. The interim (baseline) care plan for this resident was not developed until more than 48 hours after admission, exceeding the 24-hour requirement. This baseline care plan also lacked documentation of resident or representative participation or review. The comprehensive admission MDS assessment and comprehensive care plan were completed, but the first care plan meeting occurred after the comprehensive care plan was already developed, again preventing participation in the development of the baseline and comprehensive care plans. The medical record contained no documentation that a written summary of the baseline care plan was provided. In an interview, the DON confirmed that baseline care plans are discussed verbally on admission, that the facility does not complete written summaries, and that no written summaries were offered or signed for these residents.
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