Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or the resident's representative in the quarterly Interdisciplinary Team (IDT) Care Conference for the development of an individualized Comprehensive Care Plan. The resident, who had diagnoses including gastroesophageal reflux disease and hypertension, was cognitively intact and required staff assistance with activities of daily living. Despite this, the resident was not included in discussions regarding discharge plans or care goals, and was unaware of his discharge status or plans, expressing frustration about not being consulted. Record review and staff interviews confirmed that the IDT Care Conference notes did not document participation by the resident or the resident's representative, contrary to facility policy which requires such involvement to the extent possible. The facility's policies also specify that care plans should be individualized and developed collaboratively with the resident or their representative. The lack of resident involvement led to the resident's frustration and the potential for unmet physical and psychosocial needs.