Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to include a resident or her representative in the development and planning of her care plan. The resident had a history of depression, psychotic disturbance, mood disturbance, and anxiety, and her cognitive status varied from moderate impairment to intact cognition according to her MDS assessments. Documentation showed that the resident required varying levels of assistance with mobility, hygiene, dressing, and eating, and was prescribed antidepressant and opioid medications. While there was evidence of the resident's attendance at care plan meetings on two specific dates, there was no documentation that she was invited to or included in any subsequent care plan meetings. Interviews with the resident and facility staff confirmed that the resident had not been informed or invited to her care plan meetings after the documented dates. Staff responsible for notifying residents and maintaining records were unable to provide documentation of invitations or attendance for recent care plan meetings. The facility's policy stated that residents and their representatives should be encouraged to participate in care planning and that meetings should be scheduled at convenient times for them, but this was not consistently documented or followed in practice.