Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to include residents in the development and implementation of their person-centered care plans for three out of five sampled residents, all of whom were assessed as cognitively intact with BIMS scores of 15 out of 15. Interviews with these residents revealed that they either did not recall being invited to care conferences or had only been invited once, despite multiple care plan revisions and assessments occurring during their stays. Medical record reviews confirmed that care conferences were either not documented as occurring at appropriate intervals or lacked evidence of resident participation. Further review of facility policy indicated that residents and/or their representatives should be included in care plan discussions at regular intervals and after significant changes, with signatures obtained to confirm participation. However, interviews with the interim DON confirmed that while care conferences were held quarterly, there was no evidence that residents participated in the planning process as required by policy. This lack of resident involvement was consistently observed across the sampled cases.