Resident Excluded from Care Planning Meetings
Penalty
Summary
The facility failed to ensure that Resident 275 participated in care planning meetings, which is a violation of the resident's rights. Resident 275, who has a medical history of chronic obstructive pulmonary disease, hypertension, and congestive heart failure, was admitted to the facility and was capable of understanding and making medical decisions. Despite this, the resident was not invited to attend care plan meetings, as confirmed by both the resident and the Director of Nursing (DON). The DON acknowledged that it was the responsibility of the nursing or social service staff to notify and invite the resident to these meetings. The facility's policy and procedure on care planning, dated 10/24/2022, states that residents should be invited to care planning meetings if they are capable, and efforts should be made to schedule these meetings at convenient times for the resident and their family. Additionally, the facility's policy on resident rights, dated 5/1/2023, emphasizes the resident's right to be fully informed and participate in their treatment. The failure to include Resident 275 in the care planning process was identified as a deficiency by the surveyors.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Interdisciplinary Team (IDT) met with Resident 275 and conducted a care conference meeting. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/20/25, the Medical Records Director conducted an audit on all new admissions and re-admissions within the last 30 days to ensure residents had attended their baseline care conference meeting. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the Interdisciplinary Team (IDT), including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, Director of Rehabilitation (DOR), Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Care Planning" with emphasis on inviting the resident, if capable, and their family to the care planning meetings and scheduling the care planning meetings at the time of convenience for the resident and family. On 3/18/25, the Director of Nursing and Director of Staff Development in-serviced the IDT, including but not limited to Minimum Data Set Nurse and Assistant, Social Services Director and Assistant, DOR, Activities Director, and Dietary Manager on the facility's policy and procedure titled, "Resident's Rights" with emphasis on the resident having the right to be fully informed and participate in their treatment in a language that they can understand. The Medical Records Director will conduct an audit daily for 5 days, weekly for 2 weeks, and monthly thereafter on all new admissions and re-admissions to ensure baseline care plans are scheduled and the resident and/or resident representative are included in the development of the care plan. How the facility plans to monitor its performance to make sure that solutions are maintained: The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for residents' rights to attend and participate in care plan meetings for three months or until compliance is met.