Failure to Involve Resident and Responsible Party in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and the resident’s responsible party were notified of and given the opportunity to participate in the development and implementation of the resident’s person-centered plan of care. The resident had been initially admitted and later readmitted with diagnoses including paranoid schizophrenia, bipolar disorder, and generalized anxiety disorder, and had a documented responsible party. Review of multidisciplinary care conference (MCC) records for two meetings showed no indication that the resident or the responsible party attended. The Minimum Data Set for the resident indicated moderately impaired cognitive skills for daily decision-making, independence with certain mobility tasks, and that participation in assessment and goal setting involved the resident and legal guardian. During concurrent interview and record review, the Interim Director of Nursing confirmed that there was a place in the MCC documentation to record notification of the responsible party, and acknowledged that the responsible party was not notified of the MCC held after readmission and was not notified of the quarterly MCC. The IDON explained that MCC meetings are used to discuss resident needs, changes, and recommendations to the plan of care, and that the responsible party needed to be included so they would be aware of the resident’s status and able to contribute to the plan of care. The facility’s policy on interdisciplinary care planning stated that the resident, family, and/or legal representative or surrogate are encouraged to participate in the development and revisions of the resident’s care plan, but this did not occur for this resident and responsible party for the identified MCCs.
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