Failure to Involve Resident Representatives in Care Planning
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans. Specifically, for two residents with severe cognitive impairment, the facility did not invite their representatives to attend care conferences, nor was there documentation that such invitations were made. The facility's policy requires resident and, if agreed, family participation in care planning, with attendance to be documented in the medical record. For one resident with Alzheimer's disease, bipolar disorder, and other significant health issues, the representative reported not being contacted or invited to care conferences, and the medical record lacked evidence of any such communication or attendance. Similarly, for another resident with anoxic brain damage and dementia, the representative stated she had not been invited to care conferences for over a year, despite previously participating by phone. Record reviews for both residents showed that the sections for documenting representative attendance at care conferences were left blank, and there was no evidence in the electronic medical records that representatives were contacted for multiple care conferences. Interviews with facility staff indicated that while care conference schedules were communicated internally and residents were informed, there was no consistent process or documentation to show that representatives were notified or invited. Staff acknowledged that representatives could participate by various means, but could not provide documentation that this occurred for the residents in question. The lack of documentation and communication with representatives led to the deficiency in involving them in the care planning process.