Failure to Involve Resident and POA in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and the resident's Power of Attorney (POA) were invited to participate in the development and implementation of the resident's person-centered care plan. Review of facility policies indicated that both the resident and their representative should be provided with a summary of the baseline care plan within 48 hours and be involved in the comprehensive care planning process. However, documentation in the electronic medical record did not show that the resident or POA were invited to or attended care plan meetings, nor was there evidence that they received copies of the care plan or signed acknowledgments. Interviews revealed that the POA had expressed concerns about the resident's care and had made multiple attempts to contact the facility to participate in care planning, but these calls were not returned. The Clinical Reimbursement Coordinator stated that only the resident was invited to care plan meetings unless the resident specifically requested family involvement, despite the resident having moderate cognitive impairment as indicated by a BIMS score of 11. The administrator later confirmed that both the resident and their representative should have been invited, but this was not done in this case.