Failure to Document Family Invitations to Care Plan Meetings
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with its documentation policy for one resident whose clinical record was reviewed. The resident was an elderly female with sequelae of cerebral infarction, dysphasia, gastrostomy status, anxiety disorder, depression, and schizophrenia, and had a BIMS score of 00 indicating severely impaired cognition. Her care plan indicated she wished to remain for long-term care and included an intervention to discuss options at each care plan meeting unless otherwise notified. During observation, she was in bed and did not rouse when spoken to, preventing direct interview. Her family member reported receiving calls about changes in condition but stated he had never attended a care plan meeting in person or by phone, did not recall being told about or invited to any care plan meetings in the last year, and expressed a desire to be invited so he could be updated on her care. The Social Worker stated it was her responsibility to schedule quarterly care plan meetings and that residents and families were invited. She reported that the resident’s family had been invited several times but did not attend, and that she previously sent letters but now called the family, often making 3–4 attempts and leaving voice messages. However, she was unable to locate any documentation of these attempts and acknowledged she had not documented her efforts to invite the family. The DON and Administrator both confirmed that the Social Worker was responsible for scheduling care plan meetings, that families should be notified by phone or letter and invited to attend, and that all attempts should be documented. The facility’s documentation policy required complete and accurate documentation of all relevant communications in the clinical record. Despite this, there was no documentation in the resident’s clinical record showing that the family/legal representative had been invited to participate in quarterly care plan meetings, resulting in an incomplete medical record for the resident.
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