Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were involved in the development and implementation of her person-centered care plan. Record review showed that the resident, an elderly female with diagnoses including COPD and Alzheimer's Disease and a severely impaired BIMS score, had a care plan developed with interventions updated throughout her stay. However, documentation revealed that the last care plan meeting attended by the resident's representative was in early March, and there was no evidence of subsequent meetings or notifications to the representative after that date. Interviews with facility staff confirmed that no care plan meetings had been held with the resident or her representative since the new social worker began employment in mid-July. The social worker and administrator both acknowledged the importance of involving the resident and representative in care planning and stated that meetings should occur at least quarterly. Facility policy also required advance notice and participation of the resident and representative in care planning conferences. Despite these requirements, the facility did not provide evidence of such involvement for the resident after the March meeting.