Failure to Include Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were informed of and included in the development and implementation of a person-centered care plan. Record review showed that during the resident's stay, there was no documentation indicating that either the resident or her representative had been invited to participate in care planning meetings, had been consulted about the care plan, or had received a copy of the care plan. The resident, who had a history of COPD, emphysema, dementia, and diabetes mellitus, was moderately cognitively impaired and ambulatory with a walker. Despite these needs, there was no evidence in the medical record of any communication or invitation to the care planning process for the resident or her representative. Interviews with the resident's representative confirmed that she was not consulted or included in the care planning process, was never asked to attend a care plan meeting, and was not provided with a copy of the care plan. The DON, who was not employed at the facility during the resident's stay, was unable to find any documentation of care plan meetings or invitations for the resident or her representative. Facility policy required that residents and/or their representatives be provided with a written summary of the baseline care plan and be informed of their right to participate in care planning, but this was not followed in this case.