Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to conduct a care plan conference and did not ensure that a resident was invited to participate in the development and implementation of his person-centered care plan. Clinical record review showed that the resident, who was admitted with a below the knee amputation and end stage renal disease, was cognitively intact as evidenced by a BIMS score of 13. Despite this, there was no documentation of a care plan conference or any invitation extended to the resident to participate in the care planning process. During an interview, the resident confirmed that he had not been invited to participate in the care planning process or attend any care plan meetings. Further interviews with the DON and Admission's Director confirmed the absence of documentation showing that a care plan conference had been held or that the resident had been invited to participate. This deficiency was identified for one of 29 residents reviewed.