Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident or their designated representative was given the opportunity to participate in the care planning process, as required by regulations. Specifically, for one resident reviewed, there was no documented evidence that the resident or their representative was invited to participate in the review and revision of their care plan. The facility's policy stated that residents and their representatives should be invited to initial, annual, and significant change care planning meetings, but it was found that the representative was not invited to quarterly meetings. The resident in question was admitted with diagnoses including cerebrovascular accident, hypertension, and diabetes mellitus, and was documented as severely cognitively impaired, requiring assistance with activities of daily living. Despite the facility's policy, there was no documentation that the resident's representative was invited to care planning meetings held in October 2024 and January 2025. The facility's social worker and director of social services confirmed that the representative was only invited to the annual meeting in July 2024, and not to the subsequent quarterly meetings. Interviews with facility staff, including the registered nurse unit manager, social worker, and director of social services, revealed inconsistencies in the understanding and implementation of the care planning meeting invitation process. The director of nursing acknowledged that care planning was previously identified as an issue, and the administrator stated that the facility believed they were in compliance with care planning meetings, despite the lack of invitations to quarterly meetings for the resident's representative.
Plan Of Correction
Plan of Correction: Approved February 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Resident #38 still resides at the facility. The resident did not have any ill effect from the quarterly care plan meeting not being conducted with Resident/Resident Representative. Resident’s Plan of Care remained the same. The quarterly care plan meeting was completed with the Resident Representative via phone call. 2) How the facility identified other residents: All residents can be affected by this deficient practice. The Director of Social Services or Designee audited all resident files to assure that all residents care plan meetings have been invited with Resident/Resident Representative. The Director of Social Services or Designee audited the residents Care Plan Meeting Records. As a result of the Audit completed by Director of Social Services no other Residents were affected. 3) Measures put into place/System changes: The Care Plan Policy has been updated to ensure compliance with inviting Resident’s representatives to Care Plan Meetings. In the event of Resident’s Representative is unreachable via phone call, a mailing invite will be sent. The Social Services Department was re-educated by the Administrator on the process for all Social Workers to ensure Resident/Resident Representatives are invited for all care plan meetings as directed by State and CMS regulations. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring compliance of invitations to Care Plan Meetings with Resident/Resident’s Representatives. Every week for a year, the Director of Social Services or Designee will audit all care plan meetings to ensure compliance. The Director of Social Services or Designee will be responsible for the implementation and monitoring of the plan. The results of these audits will be presented to the quarterly QAPI meeting.