Resident Not Afforded Opportunity to Participate in Care Planning
Penalty
Summary
Facility staff failed to ensure that a resident was given the opportunity to participate in their ongoing treatment and care planning. Record review showed no evidence that the resident, who had diagnoses including dementia with behavioral disturbance, diabetes, depression, anxiety, and chronic kidney disease, was invited to participate in care planning discussions. The most recent MDS assessment indicated the resident was cognitively intact, with a score of 15 out of 15. During interviews, both the social worker and the director of social services were unable to provide documentation showing the resident's involvement in care planning, despite facility practice to invite residents to such meetings on admission, quarterly, annually, and upon significant change in status. The resident was not available for interview during the survey as they were on leave with family. No additional information or documentation was provided by staff prior to the exit conference.