Failure to Include Resident and Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure the inclusion of a resident and/or their representative in the development and implementation of a person-centered care plan. Clinical record review showed that a resident with schizophrenia and depression, who had severe cognitive impairment and was dependent on personal care, was admitted with a designated responsible party holding Power of Attorney. The care plan directed family involvement, but there was no documentation of any interdisciplinary team (IDT) meetings from admission through several months, despite facility policy requiring such meetings within specific timeframes. The facility was unable to provide evidence that an admission care plan meeting or any subsequent meetings occurred as required. A social services note eventually documented a telephone care plan meeting with the responsible party, and a later IDT care plan meeting document failed to clarify if the resident or their representative were present or invited. Interviews with staff confirmed that required care plan meetings had not been conducted as per policy, and they could not explain the omission. Facility policy explicitly required inviting the resident and/or family to all care plan conferences and developing the care plan collaboratively, but this was not followed in the resident's case.