Resident Not Included in Person-Centered Care Plan Development
Penalty
Summary
A deficiency occurred when a cognitively intact resident with diagnoses including abnormal posture, spinal instabilities, and a sacral pressure ulcer was not included in the development and implementation of their person-centered care plan. The resident required staff assistance for eating, hygiene, toileting, and transfers. The care plan dated 2/4/25 did not address discharge planning, and the resident reported that staff had not discussed discharge or invited them to any care plan or discharge planning meetings, despite the resident being ready for discharge. Interviews with facility staff revealed that there was no current MDS coordinator or Director of Social Work, and care planning responsibilities were shared among the DNS, Rehabilitation Department, and social worker. Review of care conference attendance sheets and progress notes showed no evidence of care plan meetings or resident participation after 10/24/24. The facility's policy required resident participation in care planning, but documentation and staff interviews confirmed that this did not occur for the resident in question.