Resident Not Included in Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a resident participated in the development and implementation of her person-centered plan of care. The resident, who had diagnoses including cerebral infarction, dysphagia, and liver cirrhosis, was admitted to the facility and was assessed as having the ability to express ideas and understand others. Documentation indicated that the resident required moderate assistance with daily activities and expressed a desire to participate in assessment and goal setting. However, there was no evidence that the resident or her representative attended any care plan meetings, and the Multidisciplinary Care Conference Note was incomplete with no documentation of attendance. Interviews with the resident confirmed that she had never met with facility staff to discuss her condition or medications. Staff interviews, including those with the Social Service Director, MDS Nurse, and Director of Nursing, acknowledged the importance of involving the resident or her representative in care planning and confirmed that this did not occur. Review of facility policies showed that care conferences should be held with residents or their representatives and documented accordingly, but this was not followed in this case.