Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that two residents were given the opportunity to participate in the development of their care plans, as required by both facility policy and regulatory standards. Review of the facility's policy indicated that residents and their representatives should be invited to care plan meetings, with documentation of invitations, attendance, and any follow-up efforts. However, for both residents reviewed, there was no documented evidence that they were informed of the specific date, time, or location of their care plan meetings, nor was there evidence of their attendance or participation in the care planning process. Progress notes contained vague references to contact with residents or their representatives, but lacked specific details and did not confirm who was contacted or how the information was provided. For one resident, who was cognitively intact and had been in the facility since 2016, there was no documentation of attendance at care plan meetings for two separate care plan reviews in 2025. The resident reported not being regularly invited to care plan meetings and expressed a desire to participate. The Social Services Director (SSD) was unable to find evidence of invitations or attendance records for this resident and could not explain the lack of documentation. Similarly, for the second resident, there was no evidence of participation in care plan meetings, and the resident stated he had not been invited or informed about them. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for scheduling and documenting care plan meetings. The SSD and other staff members acknowledged that invitations were supposed to be issued and attendance documented, but could not provide evidence that this had occurred. The letter used to notify residents did not include specific meeting details and implied the care plan had already been developed, rather than inviting participation in its creation. There were no sign-in sheets or other documentation to confirm resident or representative attendance, and discarded scheduling records further contributed to the lack of evidence.