F0553

D

Failure to Involve Resident Representative in Care Planning and Hospice Discussion

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident and/or their representative were offered the opportunity to participate in the development and implementation of a person-centered plan of care. Resident 5, admitted with failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease, had a quarterly MDS dated 10/30/2025 documenting severe cognitive impairment and dependence on staff for eating. A Durable Power of Attorney for Health Care designated a family member (CC5) as the decision maker if the resident could no longer make decisions. CC5 reported being shocked by the resident’s significant weight loss, which had not been communicated to him, and observed the resident eating without assistance, leading to concerns that the resident was not receiving needed care. CC5 raised concerns with the provider about the resident’s dietary status, pain, and communication with staff, and was told a care conference would be scheduled to further discuss these issues.

Progress notes dated 11/19/2025 documented that a call was made to CC5 and that a care conference would be held the following week to determine if hospice was appropriate. However, during an interview on 03/02/2026, the DON (Staff B) stated there was no follow-up with CC5 after the 11/19/2025 note and confirmed that no care conference took place. Staff B also stated that the resident was not receiving end-of-life or hospice services and that end-of-life or hospice care needed to be discussed to address the potential for further weight loss and pain. This lack of follow-through on the planned care conference and failure to involve the designated representative in care planning constituted the deficiency under WAC 388-97-0300(3)(a).