Failure to Include Resident Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was invited to participate in the development and implementation of the resident's person-centered care plan. Record reviews and interviews revealed that the resident, who had severe cognitive impairment as indicated by a BIMS score of 3 and diagnoses including Alzheimer's disease, heart failure, hypertension, and a psychotic disorder, was not able to respond to questions and relied on a responsible party for decision-making. Despite this, there was no evidence that the responsible party was invited to or included in care plan meetings. Interviews with facility staff, including the social worker (SW), MDS coordinator, and administrator, confirmed that the SW was responsible for coordinating care plan meetings and inviting responsible parties or family members. However, the SW admitted to not having coordinated a care plan meeting for the resident in question during her tenure. The responsible party also reported never being invited to a care plan meeting, despite being contacted for medical consents and expressing a desire to be included. The MDS coordinator could not recall if the responsible party was invited to the most recent care plan meeting and was unable to provide sign-in sheets or documentation showing their participation. Review of the resident's care conference assessments showed attendance by facility staff but no indication that the responsible party or family attended. Additionally, the facility's policies required resident and/or representative participation in care planning and outlined procedures for notifying them in advance, but these were not followed in this case. Documentation for some care plan meetings was missing, further indicating a lack of compliance with established procedures.