Failure to Document Resident and Representative Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and her representative were given the opportunity to participate in the development and implementation of her person-centered care plan. Record review showed no documentation of any care plan meetings involving the resident or her representative during her stay, despite the care plan being initiated and interventions updated throughout her admission. The resident had moderate cognitive impairment due to unspecified dementia, and her representative reported only one care plan meeting occurred during a seven-month stay, with no evidence of quarterly meetings as required. Interviews with facility staff, including the DON, LMSW, and CMS Nurse, confirmed that care plan meetings should have been held and documented quarterly, after changes in condition, or as needed. However, none of the staff could locate documentation of these meetings for the resident, and only recalled participating in a single meeting. Facility policy required that care plan meeting discussions be documented in the nursing progress notes, but this was not done for the resident in question.