Failure to Involve Residents and Representatives in Ongoing Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain complete, interdisciplinary care plans with resident and representative participation, as required. Record review showed that one resident admitted with multiple diagnoses including cerebral infarction, chronic pain, carotid stenosis, depression, anxiety, aphasia, diabetes, hypertension, atrial fibrillation, and hyperlipidemia had an MDS indicating moderately impaired cognition and moderate depression. This resident reported not remembering ever having a care conference with the IDT to discuss care concerns or his care plan. His guardian, assigned in August 2025, stated she had not been invited to or attended any care conference for him. The Administrator confirmed there was no documented evidence of care conferences or IDT plans of care for this resident since 2024. Two additional residents, both cognitively intact per their MDS assessments and with extensive medical histories including quadriplegia, toe amputations, atherosclerosis of the aorta, diabetes, prior myocardial infarction, colostomy, malnutrition, alcohol abuse, mood disorder, hypertension, contractures, and neurogenic bladder, also reported lack of ongoing care conference involvement. One resident stated he had only one care conference upon admission and had not been invited to or had any additional care conferences, and that he had never seen his care plan or been told what was in it. The other resident reported not being invited to or attending a care conference since transitioning from skilled care to LTC in late 2024 and stated she had not seen her care plan nor been informed of its contents. The SSD reported that care conferences are done on admission, quarterly, annually, and upon request, and that residents and responsible parties are invited, but also acknowledged that few attend. The Administrator verified there was no documented evidence of care conferences or IDT plans of care for these residents since 2024, affecting three of four residents reviewed for care planning and care conferences.
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