Failure to Update and Involve Residents in Care Planning for Smoking and Discharge
Penalty
Summary
The facility failed to ensure that each resident and/or their representative, as well as the interdisciplinary team (IDT), were invited to participate in care plan meetings for both comprehensive and quarterly review assessments. Specifically, two residents were not included in these meetings as required. Additionally, the care plans for these residents were not revised in a timely manner to accurately reflect their current smoking status, despite both having completed smoking evaluations indicating they were independent and safe smokers. For one resident, the care plan did not include any information about smoking, even though a smoking evaluation had been completed and indicated the resident had recently started smoking. The other resident's care plan also lacked documentation of smoking status and did not address discharge planning, despite the resident having a completed smoking evaluation and being admitted for several months. Both residents' Minimum Data Set (MDS) assessments did not reflect tobacco use or smoking, and their care plans were not updated to include this information until much later. Interviews with facility staff, including the MDS coordinator, DON, and administrator, confirmed that the care plans for smoking were not implemented until after the residents had already begun smoking. Staff acknowledged that discharge planning should have been included in the care plan for one resident but was not. The facility's policy requires comprehensive, person-centered care plans that address all identified needs, but this was not followed in these cases.