Failure to Involve Resident and Guardian in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and her legal guardian were invited to participate in the development and review of her person-centered care plan. Multiple care conferences corresponding to the resident's Minimum Data Set (MDS) assessments, including annual, quarterly, significant change, and admission, lacked documentation showing that either the resident or her guardian were invited or attended. Progress notes and care conference forms did not consistently record invitations or attendance, and in some cases, there was no follow-up after initial outreach attempts. Interviews with staff confirmed the absence of documentation regarding invitations and participation of the resident and her guardian in care conferences. The resident, who had diagnoses of heart failure, diabetes, and dementia, was assessed as able to make herself understood and had modified independence in daily decision-making. She expressed a desire to participate in care conferences and voiced concerns about not being included since the appointment of her legal guardian. The resident also reported unmet personal needs and preferences, such as wanting access to personal belongings and assistive devices. Staff interviews and document reviews confirmed the lack of evidence that the resident or her guardian were involved in care planning as required.