Failure to Involve Residents in Person-Centered Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their legal representatives participated in the development and implementation of person-centered care plans for three of five sampled residents. Specifically, after the completion of comprehensive and quarterly Minimum Data Set (MDS) assessments, there was no evidence that residents or their representatives were invited to attend interdisciplinary care plan meetings as required by facility policy. For example, one resident with a history of multiple back surgeries, diabetes, bipolar disorder, and chronic pain, who was cognitively intact, reported never being invited to a care plan meeting, and there was no documentation of such meetings in the medical record. Another resident with moderate cognitive impairment and diagnoses including atrial fibrillation and depression also had no documentation of being invited or attending a care plan meeting after their annual MDS. A third resident with anemia, cirrhosis, diabetes, and a history of falls, and moderate cognitive impairment, similarly had no evidence of being scheduled for or invited to a care plan meeting. Interviews with facility staff, including the Director of Social Services, MDS Nurse, and Director of Nursing, confirmed that the process for inviting residents and their representatives to care plan meetings was not consistently followed. Staff acknowledged that it was the facility's expectation for all residents and families to be invited to these meetings, but could not provide documentation or explanation for the missed invitations and meetings for the affected residents. The deficiency was identified through record review and staff and resident interviews, which revealed a lack of compliance with both facility policy and regulatory requirements regarding resident participation in care planning.