Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was given the right to participate in the development and implementation of her person-centered plan of care. Despite having quarterly Minimum Data Set (MDS) assessments completed, there was no evidence that care plan meetings were conducted or that the resident was invited to participate in such meetings after her initial care plan conference. The resident, who had diagnoses including a mental disorder, vascular dementia, multiple sclerosis, and major depressive disorder, and who demonstrated no cognitive impairment with a BIMS score of 14, reported never attending a care plan meeting to discuss her care. She expressed uncertainty about the assistance being provided and her continued stay at the facility, as well as dissatisfaction with the handling of her dental issues. Interviews with facility staff, including the Unit Manager, MDS Nurse, DON, and Administrator, revealed a lack of clarity regarding the scheduling and requirements for care plan meetings. Staff indicated that care plan meetings were typically held upon admission or when requested by family members, but could not confirm that quarterly meetings were held for the resident in question. Review of facility policy indicated that residents should be informed of and participate in care planning at regular intervals, but documentation and staff interviews did not support that this occurred for the resident after her initial admission.