Failure to Provide and Review Baseline Care Plan Summaries With Residents/Representatives
Penalty
Summary
The facility failed to provide a summary of baseline care plans to residents and/or their representatives and did not ensure that baseline care plans were clearly based on admission orders. For one resident with Alzheimer’s disease and dementia who was confused and oriented only to person, the medical record showed an admission assessment and a multidisciplinary care conference where staff documented that medications were discussed and that a copy of the plan of care was offered. However, the resident’s power of attorney (POA) reported not recalling any discussion of medications as part of the admission care conference and not being offered or given a copy of the baseline care plan. The Social Service Designee confirmed that the form only allowed staff to mark that a copy was offered to or received by the resident, that the resident was very confused with poor vision, and that there was no evidence a copy of the baseline care plan was provided to the POA. For another resident with multiple diagnoses including COPD, ventilator dependence, chronic respiratory failure, morbid obesity, heart failure, diabetes, and significant functional dependence, the multidisciplinary care conference form indicated that admission, goals, therapy, discharge, health, and code status were discussed, that the plan of care was reviewed, and that the resident was offered a copy of the plan of care. The form did not show that initial goals were based on admission orders or that physician orders, including dietary orders, were reviewed. The resident stated that medications and treatments were not reviewed at the conference, that she was not asked if she wanted a copy of the care plan, and that no one asked about or provided compression hose, which she had used at a prior facility for edema. The Social Service Designee verified that the facility did not provide copies of baseline care plans unless requested and that there was no documentation of physician orders, medications, treatments, or dietary orders being reviewed during the meeting. The facility’s care plan policy required resident or sponsor signatures to verify presence and review of the care plan but did not address providing a copy of the baseline care plan as required by regulation.
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