Failure to Update Care Plan and Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their representative were included in care planning meetings and did not update the resident's care plan to reflect a change in code status to Do Not Resuscitate (DNR) after the resident was admitted to hospice care. The resident, who had diagnoses including type 2 diabetes mellitus, paranoid schizophrenia, and Alzheimer's disease, was severely cognitively impaired and unable to make decisions. Despite a DNR order being present in the resident's medical record, the care plan continued to indicate that the resident was a full code and directed staff to initiate CPR if necessary. Interviews with facility staff revealed that the MDS Coordinator was responsible for updating care plans and conducting care plan meetings, but the resident's care plan was not revised to reflect the DNR status. The MDS Coordinator also did not have documentation of recent care plan meetings with the resident's family, and the resident's name was missing from the care plan meeting schedule. The family member confirmed that no care plan meeting had occurred since several months prior, and there was no documentation explaining the lack of participation or attempts to include the resident or representative in the care planning process.