Failure to Ensure Resident Participation in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were allowed to participate in the development and implementation of person-centered care plans by not conducting interdisciplinary care plan meetings as required. Multiple residents, including those with severe cognitive impairment and those with legal guardians, did not have documented evidence of quarterly care plan meetings or participation by their representatives. For example, one resident with Alzheimer's Disease and a legal guardian had no documentation of care plan meetings in either the paper or electronic medical record, aside from a single note indicating an attempt to schedule a meeting with the guardian. Other residents, including one with hemiplegia and another with severe cognitive impairment, also lacked documentation of care plan meetings within the past year. Interviews with the Director of Nursing revealed uncertainty regarding the scheduling and requirements for care plan meetings, and it was confirmed that if such meetings had occurred, they would be documented in the medical record. The facility was without a social worker at the time of the survey, further contributing to the lack of care plan meeting documentation and resident participation. Facility policies require that residents and their representatives be encouraged to participate in care planning, with advance notice provided and records maintained of such notices. The interdisciplinary team is responsible for developing individualized care plans, and every effort should be made to schedule meetings at convenient times for residents and families. Despite these policies, the facility did not maintain records or evidence that these requirements were met for several residents, resulting in a deficiency related to resident participation in care planning.