Failure to Provide and Document Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to provide baseline care plans to residents or their representatives and to document this provision in the medical record for three of five residents reviewed. Facility policy "Care Plans - Baseline," version 1.2, required that the resident and/or representative be provided a written summary of the baseline care plan in an understandable language and that provision of this summary be documented in the medical record. For a resident admitted with muscle wasting and respiratory failure, there was no documentation that a baseline care plan was provided or discussed with the resident or representative. For a second resident admitted with Parkinson’s disease and malignant neoplasm of the prostate, the medical record likewise lacked documentation that a baseline care plan was provided or discussed. For a third resident, initially admitted and later readmitted with a stable lumbar vertebral fracture and repeated falls, there was also no documentation that a baseline care plan was provided or discussed. On interview, the RNC confirmed there was no documentation that these residents or their representatives had received copies of their baseline care plans. This deficiency centers on the facility’s noncompliance with its own baseline care plan policy and the absence of required documentation in the medical records for multiple residents with significant medical conditions.
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