Failure to Notify and Involve Residents and Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care conferences as required by policy. In multiple cases, there was no documented evidence that residents or their legal representatives were notified of or attended care plan meetings. This deficiency was identified through record reviews, interviews, and examination of care conference attendance records and facility policies. For example, one resident with multiple diagnoses including COPD, dementia, and chronic respiratory failure, had a legal guardian who reported never being invited to or attending a care conference. The resident herself also stated she did not attend care plan meetings, and documentation confirmed the absence of invitations or attendance records for both the resident and her guardian. Another resident, who was cognitively intact but had a legal guardian, similarly had no documentation of being invited to care conferences, and the guardian stated he was not notified of meetings unless he initiated contact with the facility. Additional cases included residents with moderate to mild cognitive impairment and their representatives, who reported never being invited to care conferences or informed of changes in care. Facility staff interviews revealed that notifications were often made verbally and not documented, with staff relying on memory rather than maintaining records as required by facility policy. The policy specified that a seven-day notice should be provided and documented, including the method of contact and any input or refusal, but this was not followed in the reviewed cases.