Failure to Include Resident Representatives in Care Planning
Penalty
Summary
The facility failed to ensure the inclusion of residents' representatives in the care planning process for two residents with severe cognitive impairment. One resident, who was observed to have dementia and a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was unable to make significant decisions regarding his care. The resident's representative confirmed that while the resident could make minor day-to-day choices, he was not capable of making major decisions. Despite this, the representative was not invited to participate in the resident's care plan meeting and was not given the opportunity to provide input on the resident's goals, choices, and preferences. Documentation confirmed that only the resident was listed as attending the care plan meeting, and staff acknowledged that there was no record of the representative being notified or invited. For the second resident, also with severe cognitive impairment as indicated by a low BIMS score, the family representative reported that care planning meetings were sporadic and that formal meetings were not consistently conducted. Review of the electronic health record and interviews with staff confirmed that the last care planning meeting for this resident was held several months prior, and the required quarterly meeting was missed. The process for scheduling and documenting care planning meetings was described, but it was confirmed that the necessary meeting for this resident did not occur as required. These findings demonstrate that the facility did not facilitate the participation of residents' representatives in the care planning process for residents who were unable to make their own significant care decisions. As a result, the representatives were not able to support or provide input on the residents' care plans, which is a requirement for residents with severe cognitive impairment.