Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in care planning and attend care conferences, as required by facility policy. Specifically, for one resident with multiple diagnoses including renal disease, hypertension, dementia, depression, and respiratory failure, there was no documentation of care conferences with the resident or her representative from August 2024 through January 2025. The facility's policy mandates that care conferences be scheduled upon admission, quarterly, and with any significant change, and that these meetings be documented in the electronic health record (EHR). Despite the care plan instructing quarterly care conferences, the resident's representative reported not being contacted about any care conferences since the previous summer. The Director of Nursing (DON) confirmed that while care conferences were being completed and placed in the nursing progress notes, they were documented incorrectly, resulting in no record of who attended or what was discussed. This lack of proper documentation and communication led to the deficiency identified during the review.