Resident Excluded from Care Plan Meeting Despite Intact Cognition
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of their person-centered plan of care. This deficiency was identified for a cognitively intact resident who had no known family or designated representative. Despite having a Brief Interview for Mental Status (BIMS) score indicating intact cognition, the resident was not invited to their Comprehensive Care Plan meeting. The facility's policy requires that residents, along with their families or legal representatives, be encouraged to participate in care plan development and revisions. However, the resident was excluded from the meeting due to perceived periods of confusion, without an assessment of their mental status on the day of the meeting. The resident, who has diagnoses including Schizophrenia, Anxiety Disorder, and Depression, expressed a desire to be involved in their care plan meetings. Interviews with facility staff, including the Social Worker and the Director of Social Services, acknowledged that the resident should have been invited to participate in the meeting. The Administrator also confirmed that it is a resident's right to be invited to their care plan meeting, especially if they are cognitively intact. This oversight was documented during the Recertification Survey, highlighting a failure to adhere to the facility's own policies and procedures regarding resident participation in care planning.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 F 553 – Right to participate In Plan of Care The following plan of correction is submitted in accordance with applicable law and regulation and for continued Medicare/Medicaid certification and does not constitute an admission of fault on the part of the facility. A) Immediate Corrective Action for Resident found to be affected by the deficient practice: a) An invitation was issued and Resident #93 participated in his person-centered plan of care on 12/18/2024. b) The Social Worker who failed to invite Resident #93 to participate in his care plan meeting received educational disciplinary action on 01/13/2025. B) Identification of other Residents having the potential to be affected by the deficient practice: All cognitively intact residents without family or legal representative are at risk for this deficiency. A list was compiled of all current Residents who had a care plan meeting scheduled from the timeframe of (MONTH) 15, 2024 to (MONTH) 31, 2024. Utilizing this list, an audit was created and completed to ensure the Residents and/or their legal representative were invited to participate in their plan of care. Any negative findings were immediately corrected by issuing invitations and convening a care plan meeting. Person responsible: Assigned Unit Social Worker C) Systemic Changes to ensure the deficient practice will not recur: The “Care Planning – Interdisciplinary Team” policy and procedure with a review date of 01/2025 was reviewed and found to be in compliance. All Social Workers responsible for the enforcement of issuing invitations and facilitating the care planning meetings will be re-educated on the facility’s policy and procedure regarding same. Education will be verified by posttests or return demonstration to ensure education retention. Person responsible: Staff Educator D) QA – Monitor of the deficient practice: The Director of Social Work will conduct audits of all residents scheduled for care planning to ensure that Residents and/or their representatives are invited to participate in the care planning process. Any negative findings will be immediately corrected and results of findings will be reported to the QAPI committee quarterly. This audit will be conducted weekly x 3 months then monthly x one year. The Director of Social Work is responsible for the correction of this deficiency. Date of correction: 02/18/2025