Failure to Involve Resident in Care Plan Development and Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident participated in the development of their comprehensive care plan or was invited to attend the initial care plan meeting, as required by facility policy and federal regulations. The resident, who was admitted with a right femur fracture and had moderately impaired cognition, required partial assistance with most activities of daily living and had an active discharge plan to return to the community. Despite documentation in the care plan and therapy notes indicating discharge planning and the resident's preferences, there was no evidence of a care plan meeting invitation, attendance sheet, or documented conversations with the resident or their family regarding the plan of care or discharge goals. Interviews with staff revealed that the process for scheduling and documenting care plan meetings was not consistently followed. The social worker responsible for scheduling care plan meetings stated that invitations were typically hand-delivered to residents and families were called, with attendance sheets signed at meetings. However, in this case, the social worker acknowledged that conversations with the resident about discharge planning were not documented, and no care plan or discharge meeting had been held or scheduled for the resident. The Director of Social Work and the Minimum Data Set Coordinator both confirmed that the resident had not been scheduled for a care plan meeting within the required timeframe due to a failure to enter the review date into the system. The resident reported not attending a care plan meeting, not knowing when they would be discharged, and not receiving information about their discharge plan despite asking staff daily. Staff interviews confirmed that while the resident was discussed in Utilization Review meetings, this information was not communicated to the resident or their family, and required documentation and resident participation in care planning did not occur as per facility policy.