Failure to Ensure Resident Participation and Interdisciplinary Team Presence in Care Planning
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to participate in the development of their care plans and that care plan meetings included an interdisciplinary team (IDT) as required. For one resident with diagnoses including type two diabetes mellitus, major depressive disorder, and cellulitis, there was no evidence of any care conferences or opportunities for participation in care planning over a period of more than six months, despite the resident being cognitively intact. Another resident with a history of traumatic brain injury, functional quadriplegia, and multiple psychiatric diagnoses had only one care conference documented in over seven months, with no further opportunities for participation in care planning during that time, even though the resident was also cognitively intact. A third resident with chronic kidney disease, diabetes, and anxiety disorder had care conferences documented, but attendance was limited to social services, a unit manager, and the resident's family by phone, with no other IDT members present. Facility policy requires that the care planning team include a range of clinical and support staff, as well as the resident and/or their representative, to ensure a holistic approach to care. Interviews with staff confirmed that the required IDT members were not present at these care conferences and that residents were not consistently offered the opportunity to participate in their care planning.