Failure to Involve Resident and Family in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident and her family representative were invited to and participated in the development and implementation of her person-centered care plan. Despite facility policies requiring that residents and their representatives be provided with a written summary of the baseline care plan and be included in care plan meetings, documentation and interviews revealed that neither the resident nor her family were invited to the 72-hour care plan meeting following admission. The resident, who was admitted with diagnoses including dysphagia and gastro-esophageal reflux disease and had intact cognition as indicated by a BIMS score of 15, did not have evidence of participation in the care planning process. Further review of records and staff interviews confirmed that the required care plan meetings were not held as scheduled, and the family only became aware of care planning issues after inquiring about therapy discontinuation. The family reported not receiving any invitations or communications regarding care plan meetings until after they initiated contact. Staff interviews corroborated that the care plan meetings were not conducted according to policy, and there was no documentation of resident or family involvement in the initial or subsequent care plan meetings.