Failure to Involve Resident and Representative in Care Plan Conference
Penalty
Summary
The facility failed to conduct a care plan conference and offer a resident and her representative the opportunity to participate in the person-centered care planning process. The resident, who was cognitively intact and had multiple complex medical conditions including deep vein thrombosis, atrial fibrillation, a recent hip fracture, pressure wounds, and dietary restrictions, was admitted and later discharged without documentation of a care plan conference. Although a care plan was created, there was no evidence that the resident or her representative were involved in its development or implementation. Interviews revealed that the resident and her representative were told a care plan conference would occur, but staff did not attend the scheduled meeting, and the conference was not rescheduled. The resident representative made several inquiries but did not receive updates or progress reports. Staff interviews indicated confusion and lack of clarity regarding responsibility for documenting care plan conferences, with no clear process in place to ensure documentation in the electronic medical record. As a result, there was no record that the resident or her representative participated in the care planning process.