Failure to Involve Residents or Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences included the input of residents or their representatives for five residents who were reviewed for care conferences. Each of these residents was identified as being severely cognitively impaired, with diagnoses including dementia, Alzheimer's disease, hypertension, arthritis, seizure disorder, Parkinson's disease, heart failure, and hemiparesis or hemiplegia. Despite their cognitive impairments, there was no documentation in the medical records that the residents, their representatives, or family members had been contacted prior to care conferences or the implementation of changes to their care plans. Care plan summaries for these residents showed input from nursing, social services, and dietary staff, but consistently lacked any indication of involvement from the resident, their representative, or family members. Interviews with facility staff revealed that the social services director was responsible for care conferences and typically sent out care plan summaries to staff for input, then mailed the completed summary to families for review. If families did not respond or request a meeting, no in-person care conference was conducted, and one-to-one meetings with residents occurred only after care plan revisions. Family members confirmed they had not been made aware of or included in care conferences, nor asked to provide input regarding treatment and services. The facility's own policy required that care plans be reviewed at a care planning meeting with the resident and/or representative, and a summary shared with them. However, the process in practice did not ensure resident or representative participation prior to care plan changes, as evidenced by the lack of documentation and family reports of not being included. The administrator acknowledged the need for a process change to involve families more in guiding care, confirming that the current approach did not meet expectations for resident and family involvement.