Failure to Involve Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans for two residents out of a sample of twelve. Both residents were cognitively impaired, with BIMS scores of zero, and required significant assistance with daily activities. For one resident, the representative reported only being invited to the initial care conference upon admission and had not been invited to any subsequent conferences for several months, despite attempts to contact social services. Documentation confirmed that no care conferences had occurred for this resident between July and December, except for a voicemail left during the survey period. For the second resident, the representative stated difficulty in scheduling care conferences and could not recall the last time one was held. The facility's records indicated that the representative did not attend the last documented care conference due to unsuccessful contact attempts, and there was no evidence of any further care conferences in the following months. Staff interviews confirmed that the facility was behind in scheduling both initial and quarterly care conferences for all residents, including the two in question, and that documentation of contact attempts was expected but not consistently completed.