Failure to Offer or Hold Care Plan Meetings for Residents
Penalty
Summary
The facility failed to ensure that residents were offered or included in care conference meetings as part of their person-centered care planning. Record reviews and interviews revealed that four residents, all of whom had quarterly Minimum Data Set (MDS) assessments completed and were either cognitively intact or had a representative, did not have documented care plan meetings beyond their initial or early admission meetings. For example, one resident was only invited to a single meeting after admission, which he missed, and had no further documented invitations. Another resident and his mother reported not receiving invitations to care plan meetings for an extended period, and the last documented meeting was several months prior. A third resident's family stated they were not contacted or invited to participate in care planning, and the last meeting on record was also several months old. The fourth resident, who was cognitively intact, reported not being involved in any care plan meetings during his year-long stay, with the last documented meeting occurring months before the review. Interviews with facility staff, including a licensed social worker and an LPN, confirmed that care plan meetings were not consistently offered or held for all residents as required. The social worker identified issues related to staffing changes and lack of a systematic approach to scheduling these meetings. The facility's own policy stated that residents and their representatives should be included in all aspects of care planning and be given opportunities to participate, but this was not followed in practice. The deficiency was identified during a complaint investigation and affected four out of four residents reviewed for participation in care planning.