Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The facility failed to include a resident's representative in the development and implementation of the resident's person-centered plan of care. The resident, who had moderate cognitive impairment and diagnoses including traumatic brain injury, stroke, and hemiplegia, had a designated family member as her power of attorney and responsible party. Despite this, the facility did not inform or involve the representative regarding a podiatry referral for the resident's bilateral toe sores, nor did they update her when the resident declined the podiatry service. Additionally, the facility did not provide updates to the representative about the status of a requested nerve block injection appointment, which had been discussed during a care conference and requested by the family due to the resident's increased discomfort. Interviews with facility staff confirmed that communication with the resident's representative was lacking. The care coordinator acknowledged not contacting the representative about the podiatry referral, and the health information manager was unaware of the resident's refusal of podiatry services. The representative confirmed she had not been updated on either the podiatry referral or the nerve block appointment. The regional nurse consultant stated that the representative should have been involved and updated when new orders or consents were needed, and that the care team should have addressed the appointment request made during the care conference.