Failure to Invite Residents and Representatives to Care Plan Meetings The facility did not document advance notice or invitations for care plan/IDT meetings for multiple residents, including residents with dementia, cognitive impairment, mobility limitations, pain needs, wounds, therapy services, and complex medical diagnoses. Interviews showed residents and family members were not invited to meetings, and staff stated the IDT discussed care plans internally while the DON called families with updates instead of holding or documenting formal care plan conferences.
Failure to Invite Residents and Representatives to Care Plan Meetings: Two residents were not consistently included in quarterly care plan conferences. One resident with anemia, A-fib, cirrhosis, and moderate cognitive impairment said she had never been invited to a care plan meeting, and a second resident with Parkinson's disease had a family member who said she had not been invited in a while. The SW said she sent invitation letters and that some meetings may have been missed during a period when staffing was limited, while the DON and Administrator stated care plan meetings should occur quarterly with the resident, family, and IDT.
Failure to include POA in care planning: A resident with bipolar disorder and dementia, and a BIMS score indicating severe cognitive impairment, was not shown to have his family member/POA included in care plan meetings or the formulation of his person-centered plan of care. The family member stated she was the legal POA for medical and financial decisions and had not been invited to any care plan meeting since admission, while the DON said family members were not routinely invited to participate in care plan meetings.
Residents were not included in their care plan conferences and the facility lacked documentation showing quarterly person-centered planning meetings occurred for several residents. Residents with diagnoses including CVA, diabetes, cerebral palsy, parkinsonism, and heart failure reported they had not been invited or had not participated in meetings where they could discuss meds, ADLs, food preferences, and other care needs. The SW stated the care plan conference form would need to be in the EHR for the meeting to be considered held, and the DON and Administrator acknowledged the responsibility for ensuring resident and IDT participation.
A resident with multiple diagnoses and no cognitive impairment was not included in the development or review of her care plan after her initial admission. Despite regular MDS assessments, there was no evidence of care plan meetings or invitations for her participation, and staff interviews revealed uncertainty about care plan meeting requirements and scheduling.
A resident with severe cognitive impairment and multiple diagnoses was not included, nor was their representative invited, in care plan meetings. Facility staff confirmed that the responsible party was not contacted for participation, and documentation of their involvement was lacking, despite facility policy requiring such inclusion.
A resident with severe cognitive impairment and multiple diagnoses did not have care plan meetings held with her or her representative for several months, despite facility policy and staff acknowledgment that such meetings should occur at least quarterly. Documentation showed the last meeting attended by the representative was in March, with no evidence of further involvement or notification.
A resident with multiple chronic conditions and moderate cognitive impairment, along with her representative, was not informed of or included in the development or review of her person-centered care plan. There was no documentation of invitations to care plan meetings or provision of care plan summaries, and the representative confirmed she was not consulted or given a copy of the care plan, contrary to facility policy.
The facility did not ensure that residents and their representatives were invited to participate in care plan meetings, as required by policy. Several residents with varying levels of cognitive impairment and complex medical needs, as well as their family members, reported not being informed or involved in care planning. Documentation lacked evidence of invitations or attendance, and staff could not provide proof of communication regarding care plan meetings.
A resident with severe cognitive impairment and dementia was not provided with care plan meetings that included her representative, as required. The facility did not document or conduct quarterly care plan conferences, and the resident's representative confirmed she was never invited to participate. Staff interviews revealed that the responsibility for organizing these meetings was not fulfilled, resulting in the representative's exclusion from the care planning process.
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