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F0657
D

Failure to Involve Resident's Representative in Care Plan Meetings

Sunland, California Survey Completed on 12-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to involve a resident's representative or responsible party during the Interdisciplinary Team (IDT) care plan meetings, both quarterly and annually, for one resident who was reviewed under the accidents care area. The resident in question was admitted with diagnoses including hemiplegia following a stroke, aphasia, and was documented as severely cognitively impaired and unable to make decisions. The Minimum Data Set (MDS) and History and Physical (H&P) confirmed the resident's severe cognitive impairment and lack of decision-making capacity. Despite this, the facility's records indicated that the resident did not have any emergency contacts listed at admission, and subsequent care plan conference summaries showed that the responsible party was contacted only once by phone and did not return the call or attend the meeting. Further review and interviews with facility staff, including a Registered Nurse and the Director of Nurses (DON), confirmed that only a single attempt was made to contact the responsible party, with no documented follow-up efforts. The facility's policy and procedure on care planning emphasized the importance of involving the resident's family or legal representative in the development and revision of the care plan and making every effort to schedule meetings at convenient times. However, the lack of adequate follow-up to ensure participation resulted in the resident's representative not being involved in the care planning process.

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