Resident Not Included in Care Plan Development
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a cerebral infarction, dysphagia, and moderately impaired cognition was not involved in the development or implementation of their person-centered care plan. The resident reported that neither he nor his family had been included in care conferences, and he could not recall ever being involved in the care planning process. Review of the clinical record confirmed that the last documented care conference occurred nearly a year prior, despite the resident's need for assistance with personal care and ongoing medical conditions. Further review of the resident's record showed that the most recent care conference was not conducted in accordance with the facility's policy, which requires regular care plan conferences and documentation of resident or representative participation. The DON confirmed the absence of recent care conference documentation and acknowledged that such conferences should occur quarterly. The facility's policy also states that if resident participation is not practicable, an explanation must be documented, which was not present in this case.