Failure to Include Resident in Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to include a resident in the development and implementation of their person-centered plan of care. The resident, admitted with diagnoses including dysphagia, aphasia, and Type 2 diabetes mellitus, was identified as having a decline in intellectual functioning and was noted as the guarantor and care conference contact. Despite being severely cognitively impaired and requiring substantial assistance with daily activities, the resident was documented as an active participant in assessment and goal setting, with a goal to return to the community. The facility was unable to provide evidence that a resident care conference (RCC) was held or that the resident or their alternate was invited to participate. There was no RCC attendance sheet, nor documentation from social services or the MDS coordinator indicating that the meeting took place or that the resident was invited. Facility policy required a care plan conference with the resident or responsible party within 48-72 hours of admission and quarterly thereafter, but interviews with staff confirmed that this did not occur for the resident in question.