Failure to Involve Resident Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident's representative was invited to participate in the development and review of the resident's person-centered care plan. The resident, an elderly female with dementia, muscle weakness, and anxiety, had been admitted to the facility several months prior. Her medical records indicated severe cognitive impairment, and her care plan included interventions to communicate with the resident and her family regarding her needs. However, there was no documentation in the electronic medical record that a care plan conference had been completed or uploaded since her admission. Interviews with the resident's representative confirmed that she had not been invited to any care plan meetings since the resident's admission. Facility staff, including the social worker, registered nurse coordinator, administrator, and MDS coordinator, acknowledged that care plan meetings should occur at least quarterly and that the social worker was responsible for ensuring these meetings were conducted. Despite this, the required care plan meetings had not taken place, and the representative had not been given the opportunity to participate in the resident's care planning process.