Failure to Conduct and Document Resident Care Plan Meeting
Penalty
Summary
The facility failed to ensure that a care plan meeting was conducted and documented for one cognitively intact resident following completion of the comprehensive assessment, as required by facility policy. The resident was admitted with diagnoses including heart failure, dysphagia, diabetes, and bipolar disorder, and had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of the resident’s current medical record showed no signature sheet or progress notes indicating that a care plan meeting had been held, and the facility was unable to provide reproducible evidence that such a meeting occurred. In interview, the resident reported not being invited to a care plan meeting, and the social services staff member confirmed she could not locate any documentation of a care plan meeting in the resident’s record, despite the facility’s care plan policy stating that residents and their representatives are to be invited and encouraged to participate in development and revision of the care plan and that efforts will be made to schedule these meetings at a suitable time.
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