| 36 |
DESERT TERRACE HEALTHCARE CENTER |
35014 |
2509 NORTH 24TH STREET |
PHOENIX |
AZ |
85008 |
2017-12-05 |
657 |
D |
0 |
1 |
6GPJ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews and policy review, the facility failed to ensure one resident (#55) was able to participate in the care planning process. Findings include: Resident #55 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed a care plan meeting invitation for the resident dated (MONTH) 1, (YEAR), which informed the resident that a care plan conference was scheduled for (MONTH) 9, (YEAR). An admission MDS (Minimum Data Set) assessment dated (MONTH) 2, (YEAR), included the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. A progress note written by the Social Service Supervisor (staff #92) dated (MONTH) 2, (YEAR), included documentation that the resident was invited to her care plan meeting. In an interview with resident #55 on (MONTH) 29, (YEAR) at 8:57 a.m., the resident stated that she was supposed to have a care plan conference, but it did not happen. She stated they told her that she was going to have one at another time, but that did not happen either. An interview with staff #92 was conducted on (MONTH) 1, (YEAR) at 11:30 a.m. She stated that resident's who are in the facility for skilled care have a care plan meeting scheduled 14 to 21 days, after their admission. She stated the residents receive an invitation, and then they are to let her know if they would like to attend or not. Staff #92 stated that care plan meetings are held on Thursdays, and the residents can choose a time that works for them. Another interview was conducted with staff #92 on (MONTH) 4, (YEAR) at 11:47 a.m. She stated that resident #55 wanted to attend, however, did not show up at the scheduled time and location for the meeting, so the meeting was held without the resident. She stated that later in the day of the scheduled conference, resident #55 reported that she had been waiting at the social workers office during the meeting time, instead of the conference room where the meeting was held. Staff #92 further stated she offered to hold another care plan conference the next week for the resident, but the resident never followed up to schedule a time. Staff #92 stated when a care conference meeting is held, there should be an IDT (interdisciplinary team) note that can be found in the resident's record regarding what was discussed in the meeting, who attended, if there were any concerns, and if there was anything that needs to be followed up on. Review of the clinical record revealed no documentation of a care plan meeting taking place in (MONTH) (YEAR). An interview with staff #92 was conducted on (MONTH) 5, (YEAR) at 3:05 p.m. She stated that there was no documentation of the care plan meeting which was held for this resident and there should have been documentation of it. In an interview with the Director of Nursing (DON/staff #66) on (MONTH) 4, (YEAR) at 3:08 p.m., she stated the expectation is that there should be documentation of the care plan meetings, whether the resident is in attendance or not, and it should be documented as to what was discussed and if there was anything to follow up on. Review of a policy titled Care Planning included that the resident should participate to the extent possible, in the development of the care plan. The policy also included that Every effort will be made to schedule care plan meetings to accommodate the availability of the resident. |
2020-09-01 |