Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their designated representative were involved in the development and implementation of the resident's person-centered plan of care. According to the facility's policy, residents and their representatives should be encouraged to participate in care planning by being given sufficient notice of care plan meetings. However, for one resident, identified as Resident 3, there was no documented evidence that either the resident or their representative were invited to or participated in the November 2024 quarterly interdisciplinary care plan meeting. Resident 3, who was admitted with diagnoses including pneumonia and chronic obstructive pulmonary disease, was noted to be severely cognitively impaired with a BIMS score of 06. Despite the resident's cognitive impairment and the involvement of a family member as the resident's representative, the facility did not document any invitation or participation of the resident or their representative in the care planning process. This was confirmed by the Director of Nursing during an interview, acknowledging the facility's responsibility to involve residents and their representatives in care plan development.
Plan Of Correction
1. Care conference for R3 was scheduled for 1/7/25 and RR is attending with resident. 2. Facility completed 30 day lookback to ensure each applicable MDS has a care conference scheduled with RR or resident invite. 3. Facility implemented new process which includes tracking form to ensure each applicable scheduled MDS has a care plan scheduled with RR and/or resident invite and completion of care plan. NHA educated RNAC and LNAC on this new process. 4. NHA/designee will audit scheduled MDS' weekly for 4 weeks and then monthly for 2 months to ensure the applicable MDS' have a care plan scheduled with RR and resident invite sent and care plan completed. 5. Audits will be submitted to QAPI for review.