Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to include and document the participation of a resident and his representative in the care planning process. The resident, who had been at the facility for nearly three weeks, was not involved in any care planning meetings. His wife, who is his representative, reported that she had not been asked to participate in a care conference or care planning meeting with the resident and the facility. The resident confirmed that he had not been included in any care planning meetings. The resident's medical history includes dementia, heart failure, kidney failure, an intestinal disorder, sepsis, a history of falls, rib fractures, and gait and mobility abnormalities. Despite having full cognitive abilities, as indicated by a BIMS score of 13/15, the resident was not involved in the care planning process. The Clinical Care Coordinator (CCC) responsible for conducting care conferences stated that a meeting was held with the resident's wife over the phone, but no other staff from the interdisciplinary team was present. The CCC also confirmed that the resident was not included in the meeting and that there was no documentation of the meetings with the resident or his wife. A review of the facility's policy on the care planning process emphasized the importance of a collaborative partnership with the interdisciplinary team, resident, and/or resident representative, and the need to provide an opportunity for the resident to participate in planning care and treatment changes. However, this policy was not followed in the case of this resident.