Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences for two of six sampled residents. Both residents had minimal or no cognitive impairment and were capable of participating in their care planning. Interviews revealed that neither resident was informed about care plan meetings, nor were they involved in discussions regarding their person-centered care, including discharge planning and goal setting. Review of their electronic medical records showed no documentation of interdisciplinary care plan meetings or discussions about initial comprehensive admission care plans, resident-specific goals, or discharge planning. Staff interviews confirmed that the process for arranging and documenting initial care plan meetings was not followed for these residents. The facility's policy requires encouraging and assisting residents or their representatives to participate in care planning, including establishing goals and discharge planning, but there was no evidence this occurred for the two residents in question. The care plans for both residents also lacked focus areas addressing discharge planning.