Failure to Involve Residents and Representatives in Routine Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with the opportunity to participate in the care planning process as required. For one cognitively intact resident, the 5‑day MDS showed intact cognition, yet review of the electronic health record revealed that neither the resident nor the resident representative were listed as attendees at multiple care plan meetings. In an interview, this resident reported never being invited to a care plan meeting since admission, was unaware that such meetings were held, and stated he would have liked to attend with his daughter to be actively involved in his care plan. The social worker acknowledged that she had not sent invitations to this resident for care planning meetings and confirmed that quarterly or annual care plan meetings with residents and/or representatives had not been completed. For another resident with dementia with psychotic disturbance, PTSD, abnormal weight loss, failure to thrive, and anemia, MDS assessments documented severe cognitive impairment. Records showed that the resident’s representative received only one written invitation to a care plan conference, which occurred in November and was documented as including the representative. The representative confirmed being notified and invited only once and was unaware that routine care plan conferences should have occurred. The social worker stated she had only been sending invitations and holding care meetings for 72‑hour post‑admission residents or when concerns were expressed, and that she was unaware she should have been inviting all residents and/or representatives on a routine basis based on the MDS calendar. She confirmed that quarterly and annual care plan meetings for all residents and/or representatives had not been completed because she did not know it was her responsibility. The administrator stated she had been made aware that annual and quarterly care plan meetings had not been completed for all residents and that residents and/or representatives were not invited to attend care planning meetings, despite her expectation that plans of care be reviewed quarterly and as needed with them.
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