Failure to Include Resident or Representative in Care Plan Development
Penalty
Summary
The facility failed to include a resident or her legal representative in the development and planning of her person-centered care plan. The resident, who had diagnoses of dementia, dysphagia, and aphasia, was documented as having severely impaired cognition and was receiving hospice services. Review of the electronic medical record (EMR) showed no documentation of care plan meetings or attendance by the resident or her representative over the past 12 months. Although letters were sent to the representative, there was no evidence of actual care plan meetings or interdisciplinary team (IDT) care plan reviews being completed and documented as required. Interviews with the resident's legal representative confirmed he was not aware of any care conferences or care plan meetings held for the resident. Social Services staff acknowledged the lack of documentation and stated that the IDT-Care Plan Review assessment would be completed after the care plan meeting, but could not explain the absence of prior documentation. The facility's policy required care plan meetings to be scheduled with the resident and family when possible, and for explanations to be documented if participation was not practicable, but no such documentation was found in the resident's record.