Failure to Involve Residents and Representatives in Care Planning Process
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were involved in the care planning process as required by both facility policy and federal regulations. Review of facility policy indicated that residents and their representatives must be given the opportunity to participate in the development, review, and revision of the care plan, and that care planning meetings should be held at times conducive to resident participation. However, for three sampled residents, there was a lack of evidence that care planning conferences were conducted with resident or representative involvement. For example, one resident's family member reported not participating in care plan meetings following a significant event, and the facility was unable to provide documentation of care conference meetings for other residents during required intervals. Medical record reviews showed that residents with significant cognitive impairments and complex medical histories, such as anxiety, blindness, repeated falls, traumatic brain dysfunction, dementia, and chronic conditions, did not have documented participation in care planning by themselves or their representatives. Interviews with facility staff, including the Social Service Director and Director of Nursing, revealed inconsistencies and assumptions regarding the frequency and documentation of care plan conferences, with the DON acknowledging that care conference meetings had likely not been conducted as required due to missing documentation.