Failure to Ensure Resident and Guardian Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their guardian participated in the development and implementation of the resident's person-centered plan of care. According to the report, the resident had severely impaired cognition and multiple diagnoses, including traumatic brain injury, diabetes, aphasia, dementia, seizures, depression, bipolar disorder, and psychotic disorder. The resident was dependent on staff for several activities of daily living. The resident's family member was identified as the emergency contact, guardian, and primary financial contact. Review of the electronic medical record showed that the required quarterly care conference, which should coincide with the Minimum Data Set (MDS) assessment, was not completed for the resident in March. The last documented care conference was in January, and attempts to contact the guardian were made but not followed up. Interviews with the DON and social services staff confirmed that care conferences are expected to be held in conjunction with MDS assessments and that documentation should be present in the resident's record. The social services staff acknowledged responsibility for scheduling and documenting care conferences and stated that the March care conference was missed, likely due to a lack of follow-up after an initial attempt to contact the guardian. Facility policy requires quarterly care conferences and assigns responsibility for coordination and documentation to the social services department.