Failure to Involve Residents and Representatives in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the development and implementation of their person-centered plans of care, as evidenced by multiple instances where residents or their representatives were not involved in care conferences or discussions regarding significant care decisions. For several residents who were cognitively intact or had decision-making capacity, there was no documentation that they were consulted or gave consent for hospital transfers, changes in code status, or the initiation of end-of-life (EOL) or comfort care services. In one case, a resident with a POLST indicating comfort-focused treatment was sent to the hospital multiple times without documented consent or re-evaluation of their preferences, and the resident later expressed a desire for more active treatment if it would save their life. Other residents with significant changes in condition, such as weight loss or the initiation of palliative care, were not included in discussions about their care plans. For example, a resident with depression and malnutrition was not informed about the discontinuation of weights or involved in decisions regarding EOL care and anti-anxiety medication, despite expressing a desire to be weighed and to have their preferences considered. Documentation was lacking to show that residents or their legal representatives were notified or involved in these decisions, and staff interviews confirmed that such conversations either did not occur or were not documented as required. Additionally, residents with severe cognitive impairment and their legal representatives were not included in care planning or notified about significant changes such as the initiation of comfort care or discontinuation of weights. In several cases, representatives reported not being aware of the resident's care status or the meaning of comfort care, and there was no evidence of care conferences or individualized care planning. The lack of resident and representative involvement was further confirmed by staff who acknowledged the absence of required documentation and individualized care plans.