Failure to Involve Resident and Representative in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or their representative in the care planning process as required. Specifically, a resident with diagnoses including type 2 diabetes mellitus, congestive heart failure, and atrial fibrillation, who had moderate cognitive impairment at one assessment and was later assessed as cognitively intact, did not have a care plan meeting conducted or documented since January 2025. Although a care plan meeting was scheduled and an invitation was sent to the resident's representative for a meeting in May 2025, there was no evidence that the resident was invited, and the meeting did not occur due to lack of response from the representative. The resident expressed that it had been a long time since any care plan meeting occurred and indicated a desire to participate in the development of his care plan and receive updates on his medical issues. Interviews with facility staff revealed that the Social Worker was responsible for scheduling care plan meetings and typically sent invitations to representatives based on the MDS assessment calendar. The Social Worker acknowledged that she missed scheduling the care plan meetings for this resident and that the resident, who was cognitively intact, could have participated in the meeting. The Administrator confirmed that care plan meetings and notifications should follow regulations and that residents and/or their representatives should be involved in care plan meetings, but acknowledged that the required meetings had not been held for this resident since January 2025.