Failure to Involve Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were invited to participate in the development and implementation of their person-centered care plans, as required by both facility policy and regulatory standards. Specifically, for three residents reviewed, there was no documented evidence that care plan conferences were conducted with the required interdisciplinary team (IDT) members, nor that the residents or their representatives were invited to participate in the care planning process. The facility's policy mandates that the IDT, including nursing, social services, activities, and other relevant staff, involve the resident and/or their representative in care plan meetings, and document if participation is not practicable. For one resident with a history of respiratory failure and Parkinson's disease, who was cognitively intact, there was no documentation of a care plan meeting or invitation to participate following both admission and quarterly MDS assessments. Although a meeting was documented between the resident and the social worker, there was no evidence that other required IDT members were present, nor that the comprehensive care plan was reviewed by the full team. The resident confirmed not being invited to participate in any care plan meetings and expressed interest in doing so. Two additional residents, one with spinal cord compression and another with hereditary ataxia, were also found to be cognitively intact or only moderately impaired, yet neither had documentation of care plan conferences or invitations to participate in the care planning process. Both residents confirmed in interviews that they had not been invited to participate in care plan meetings since admission. The Nursing Home Administrator was unable to provide documentation to show that care plan conferences had been held or that the residents or their responsible parties had been invited to participate, as required.