Failure to Involve Residents and Interdisciplinary Team in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties, as well as required staff, were included in care plan meetings, and did not revise care plans when new medications were added. For one resident, two psychotropic medications, Tramadol and Lorazepam, were started but not included in the comprehensive care plan. The DON confirmed that these medications were omitted from the care plan, with one medication having been recently initiated. Additionally, the facility's process for care plan development did not involve the full interdisciplinary team as required by policy, and there was no evidence that residents or their representatives were invited to or participated in care plan meetings. Two residents with intact cognition were interviewed and both stated they did not know what a care plan was. Review of documentation revealed no evidence of who attended care plan meetings, and the social worker confirmed that only she and the MDS coordinator were involved in preparing care plans. Letters were mailed to responsible parties, but there was no follow-up to confirm attendance, and in-house residents were not invited or informed about their care plans. These deficiencies affected three residents in a facility with a census of 91.