Failure to Involve Resident in Care Planning Process
Summary
The facility failed to ensure the participation of a resident and their representative in the development of the resident's care plan, as required by their policy and federal and state regulations. This deficiency was identified during a recertification survey, where it was found that the facility did not conduct interdisciplinary care plan meetings or provide notice of invitation to the resident or their representative for quarterly assessments. The facility's policy, revised in October 2024, mandates the creation of a comprehensive, individualized care plan for each resident, with active involvement from the resident and/or their legal representatives. However, the medical record for the resident in question lacked documented evidence of such invitations. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding care plan meetings. The Director of Social Work and other staff members confirmed that the facility only held care plan meetings for admissions, annuals, and significant change assessments, not for quarterly reviews. The Chief Nursing Officer was unaware that the interdisciplinary care plan team was not holding meetings for quarterly assessments. The resident involved, who had moderate cognitive impairment, expressed a desire to participate in the care planning process, but there was no evidence that they or their family were invited to do so.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 I. The following actions were accomplished for the residents identified in the sample: Resident #66 On 12/30/24, the IDCP Team held a meeting with the resident to review his/her plan of care and address any questions or concerns that the resident had. The resident indicated that he/she agreed with the current plan of care. The resident’s preference to be invited to and attend all care plan meetings was reviewed and documented in the resident’s record. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents could be potentially affected by the same practice. Effective 12/19/24, the IDCP Team will hold quarterly care plan reviews that includes the resident and/or representative. Residents and/or their representatives will continue to be invited to the other meetings. The IDT will meet with each resident who has had a Quarterly MDS Assessment in the past 3 months to provide an update on their plan of care. For residents who are unable to participate, the resident’s representative will be provided with an update to the plan of care. III. The following system changes will be implemented to assure continuing compliance with regulations: The Administrator, Chief Nursing Officer, and Director of Social Work reviewed the facility policy, “Care Planning,” and revised it to reflect the need to hold quarterly care plan meetings with the IDCP Team and ensure that the resident and/or representative are invited to participate. The IDCP Team was provided with education by the Director of Social Work regarding the revisions to the policy and changes to the facility’s care plan meeting protocol. All Social Workers were educated regarding the care planning process and their responsibility to ensure that residents have the right to participate in planning their care, including attending all care plan meetings. The Social Worker will ensure that all cognitively intact residents, including those who have been evaluated by Psychiatry and have can make their own decisions, and their representatives, as appropriate, are invited to all care plan meetings, including quarterly meetings. If the resident’s preference is to have a representative attend or be updated on the plan of care, this preference will be documented in the resident record and honored. The Social Worker will ensure that the representatives of residents who cannot or do not wish to participate in planning their care are invited to all meetings. Any resident who declines to participate will be provided with an update on the plan of care after the meeting if this is his/her preference. Members of the IDCP Team will follow up on concerns or questions as needed. The Social Workers were educated to document all care plan invitations and attendance, including for quarterlies, in the resident record. IV. The facility’s compliance will be monitored utilizing the following quality assurance system: An audit tool will be developed to monitor compliance with the facility’s policy to ensure residents and/or their representatives are invited to participate in all care plan meetings, including quarterlies. Director of Social Work and/or Designee will conduct a 100% review of all care plan meeting attendance records to ensure that the resident and/or representative were invited to all care plan meetings, including quarterly meetings monthly for 3 months and then quarterly for an additional two quarters. The Director of Social Work will report all care plan meeting attendance findings to the Administrator. The audit findings will be reported monthly to the QAPI Committee for 3 months and then quarterly for 2 quarters for discussion, evaluation and follow-up action. The QAPI Committee will evaluate the need for continued monitoring at the end of the reporting period. The acceptable level of compliance is 95%. Completion Date: 01/31/2025 Responsibility: Director of Social Work
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Care plan omissions were identified for two residents. One resident’s care plan did not include multiple documented diagnoses, including UTI, bleeding hemorrhoids, TBI, pneumonia, CKD, and diverticulitis, despite severe cognitive impairment. Another resident’s care plan did not include a physician order for biannual valproic acid level testing and monitoring for side effects, and the DON and MDS Coordinator stated these items should have been included.
Missed Quarterly Care Conference and Resident Participation: A resident who was cognitively intact and had HTN, arthritis, and schizophrenia did not have documented routine care conferences at the expected quarterly interval. The EMR showed care conferences were documented, but there was no evidence of one between two documented meetings, and the resident stated she had not been invited to any care meetings over the past year. The LSW and Admin both confirmed the lack of documentation and stated residents should be included when able.
A resident with cerebral palsy and depressive disorder had conflicting code status documentation in the medical record: the emergency care document showed full code, while the care plan listed DNR and no CPR. The DON stated the care plan was completed in error and should have been revised but had not been.
Missed Care Conference Participation: A resident with intact cognition was not given the opportunity to attend and participate in a care conference. Staff confirmed care conferences were expected after MDS assessments and significant changes, but the resident’s record showed no conference documented for several months, and the family member reported the last conference had been months earlier.
A resident with dementia, bipolar disorder, and HF was on hospice status, but the care plan did not identify the terminal illness as a focus area or include hospice/end-of-life interventions. The care plan only referenced hospice in limited areas such as ADL care, psychosocial support, activities, and anti-anxiety medication related to end of life. The DNS acknowledged the care plan was not revised to reflect the resident’s hospice status.
Care plans were not updated to reflect changed resident conditions, preferences, and interventions. One resident's plan still showed hospice and wound-based EBP after hospice ended and the wound healed, another still listed Influenza A after the illness had resolved, and a third did not include behavior interventions such as a door chime and bookshelf sticker or updated dining preferences. Two residents with family-requested cameras also had care plans that omitted the camera use, rationale, and related monitoring details.
Care Plan Omissions for Resident Diagnoses and Valproic Acid Monitoring
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for 2 of 32 residents reviewed. Resident #1 was admitted with diagnoses including frequent urinary tract infections, bleeding hemorrhoids, traumatic brain injury, pneumonia, chronic kidney disease, and diverticulitis, and the quarterly MDS showed a BIMS score of 7 indicating severe cognitive impairment. The resident’s care plan, revised 03/05/2026, did not include those diagnoses even though they were part of the resident’s documented medical history. Resident #8 was admitted with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, and the quarterly MDS showed a BIMS score of 6 indicating severe cognitive impairment. The resident’s order summary included a physician order dated 01/23/2025 for valproic acid level testing every 6 months in October and April, but the care plan, revised 05/14/2026, did not include that order. During interviews, the DON and MDS Coordinator stated that both residents’ omitted diagnoses and the valproic acid monitoring order should have been included in the care plans, and the MDS Coordinator identified the omission as an oversight.
Missed Quarterly Care Conference and Resident Participation
Penalty
Summary
The facility failed to provide routine care conferences to allow resident participation for one resident who was reviewed for care conferences. The resident’s quarterly MDS assessment indicated admission to the facility, cognitive intactness, and diagnoses of high blood pressure, arthritis, and schizophrenia. The resident’s EMR showed care conferences were documented on 5/2/25, 10/7/25, 12/30/25, and 3/28/26, but there was no evidence of a care conference between 5/2/25 and 10/7/25. During interview, the resident stated she understood what care conferences were but had not been invited to any type of care meeting over the past year. The LSW stated care conferences should occur at admission, then every three months and/or with a significant change of condition, and that she was responsible for scheduling and documenting them in the EMR. The LSW could not provide documentation of a care conference between 5/2/25 and 10/7/25 and stated, "If it isn't documented it didn't happen." The Administrator confirmed care conferences were expected quarterly and should include residents if able or their representative, and also confirmed there was no documentation of a care conference for the resident during that interval. The facility policy stated residents and their designated responsible party are invited to attend the initial care planning conference and sequential conferences, including annual and significant change conferences.
Care Plan Not Updated to Match Current Code Status
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect the resident’s current code status. The facility’s Care Plan policy stated that care plans would be reviewed quarterly, annually, and with a change of status to ensure they remained current. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. The resident’s medical record contained a Plan for Emergency Care and Intensity of Treatment document showing full code status, while the resident’s care plan documented DNR status and no CPR. The DON stated that the care plan had been completed in error and should have been revised but had not been.
Missed Care Conference Participation
Penalty
Summary
The facility failed to provide R10 the opportunity to attend and participate in a care conference. R10’s quarterly MDS assessment dated 5/25/26 identified intact cognition and no hallucinations, delusions, rejection of care, or behaviors. During an interview on 6/1/26, R10 stated she had not had a care conference recently and said the last one was more than 3 months ago. Review of the record showed R10’s last documented Social Service Conference was on 1/16/26, and progress notes from 1/30/26 through 6/3/26 did not show any care conference held or scheduled. Staff interviews confirmed care conferences were expected to occur quarterly, after significant changes, and following MDS assessments, but R10’s quarterly and significant change MDS assessments were not followed by a documented conference. R10’s family member stated they typically attended care conferences, and the social services staff later verified that R10’s care conference had been missed and was only scheduled after the surveyor’s inquiry.
Care Plan Not Revised to Reflect Hospice Status
Penalty
Summary
The facility failed to revise a resident’s care plan to reflect hospice status and terminal illness for one sampled resident. The resident had diagnoses including dementia, bipolar disorder, and heart failure, and the 8/14/25 Significant Change MDS indicated hospice status. Review of the care plan showed hospice-related references for ADL care, psychosocial well-being, activities, and anti-anxiety medication related to end of life, but it did not identify the resident’s terminal illness as a focus area with interventions including hospice services or other end-of-life interventions. On 6/4/26, the DNS stated the expectation was for a terminal illness to be captured with interventions including hospice services on the care plan, and acknowledged the care plan was not revised to reflect the resident’s terminal illness and hospice status.
Care plans not revised for changed conditions, behaviors, and electronic monitoring
Penalty
Summary
The facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions for three residents reviewed for care plan revision. One resident had a discharge return anticipated MDS showing moderate cognitive impairment, multiple diagnoses including cancer, septicemia, and non-Alzheimer's dementia, and hospice services. The resident's EHR showed hospice services were discontinued, but the care plan continued to identify the resident as receiving hospice care. The same resident's care plan also continued to state that Enhanced Barrier Precautions were required due to a wound, even though the wound had healed and the resident remained on EBP because of a urinary catheter. Another resident's comprehensive MDS identified moderate cognitive impairment, diabetes, CVA, and use of insulin, an anticoagulant, and an antidepressant. The resident's care plan still listed Influenza A as an active respiratory infection with an initiation date from the prior year, but the EHR did not identify ongoing signs, symptoms, treatment, or diagnosis of Influenza A. A third resident had severe cognitive impairment, dementia, PTSD, behavioral symptoms, and wandering behavior. The resident's care plan included dining preference interventions stating the resident preferred to sit alone during meals and liked to sit in the dining room by the television next to the window, but the EHR showed the resident had behavior management interventions in place, including a bookshelf sticker on the door and a door chime to alert staff when the room door opened, and these interventions were not included in the care plan. Observations showed the resident with wandering and behavioral concerns eating and sitting with other residents in the dining room rather than alone, and staff interviews confirmed the resident had become less agitated, spent more time outside the room, and that the door chime and bookshelf sticker had been implemented and were effective. Interviews also confirmed the hospice discharge, the healed wound, the ongoing catheter-related EBP need, and that Influenza A had not been present for quite some time. The DON stated care plans should be updated whenever there was a new diagnosis, condition, intervention, preference change, or other significant change in status, and that care plans served as the primary communication tool for staff. The facility also failed to update care plans for two residents with electronic monitoring in their rooms. One resident's care plan lacked the use of a camera, the rationale for it, and the fact that family had placed it for monitoring and interaction. Another resident's care plan also lacked the use of a video camera with audio capability, the rationale, and related interventions such as signage, staff awareness, and family interaction through audio. Records showed consent forms and progress notes documenting the cameras, staff notification, signage, and family involvement, but these details were not reflected in the care plans. Staff interviews confirmed that the camera use should have been outlined in the care plans and that nursing staff were responsible for updating them.
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