Failure to Involve Family Representative in Care Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct a care plan conference with the family representative for one resident who was severely cognitively impaired. According to facility policy, residents and their family members are to be encouraged to participate in the development of the comprehensive assessment and care plan, and representatives are to be invited to care planning conferences. Medical record review showed that the resident was admitted with diagnoses including dementia, diabetes, hypertension, and COPD, and had a Brief Interview for Mental Status (BIMS) score of 4 or 5, indicating severe cognitive impairment. Despite this, the resident's family representative reported never being invited to a care plan meeting. Interviews with facility staff revealed that the Social Service Director considered the resident to be his own responsible party and stated that only the resident was invited to care plan meetings. However, the Director of Nursing confirmed that with a BIMS score of 5, the resident should not be considered their own responsible party and that the family should have been invited to participate in care planning. This failure to involve the family representative in the care planning process for a resident with severe cognitive impairment was identified through policy review, medical record review, and staff and family interviews.