Failure to Conduct Regular Care Conferences
Summary
The facility failed to ensure care conferences were conducted regularly for four residents, leading to a deficiency in the development and implementation of person-centered care plans. Resident R2, who has diagnoses including high blood pressure, stroke, and schizoaffective/bipolar disorder, had care conferences documented on 04/05/23 and 09/26/23, with the next one due on 01/14/24. However, no additional care conferences were completed as per the progress notes. Similarly, Resident R8, with diagnoses including schizoaffective disorder and dementia, had the last care conference on 02/28/23, with the next one due on 05/29/23, but no further care conferences were documented. Resident R20, with diagnoses including schizoaffective disorder and Parkinson's disease, had the last care conferences on 11/17/22 and 02/28/23, with no further documentation of care conferences completed. Resident R23, who has chronic kidney disease, diabetes, and vascular dementia, was also found to have missing care conferences. The last quarterly care conference for R23 was held on 10/30/23, with the next one due on 01/28/24. The facility's social worker admitted that care conferences had not been completed but were being scheduled for the current month. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both confirmed that it is the facility's expectation to hold care conferences quarterly, but this was not adhered to. The facility's policy on care planning and resident participation, revised on 02/22/24, outlines the importance of informing residents and their representatives about their care plans and involving them in the decision-making process. The policy also emphasizes the need for regular care plan conferences and documentation. However, the facility failed to comply with its own policy, resulting in missed care conferences for the residents reviewed, thereby not ensuring their participation in the development and implementation of their person-centered care plans.
Penalty
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A resident with heart and respiratory failure, severe cognitive impairment, and dependence for all ADLs was care planned as a fall risk with a floor mat and need for extensive assistance, but no care conference was ever held to involve the resident or representative in person-centered care planning despite facility policy and staff statements that such conferences should occur shortly after admission and quarterly. Surveyors observed the resident eating breakfast from a tray placed on a floor mattress, leaning on one elbow with food falling onto the mattress, while staff reported she often crawled onto the floor, was only placed in a wheelchair when family were present, and routinely received bed baths instead of showers. The social services director, LPN, DON, and administrator confirmed that a care conference should have occurred to address preferences and needs, and a family member reported never being offered a conference, disagreed with the resident being left on the floor for hours, preferred toileting and showers, and stated that eating on the floor was not consistent with their culture.
Surveyors found that the facility did not conduct required care conferences for two residents with multiple psychiatric and medical diagnoses, including one who was cognitively intact and another with severely impaired cognition requiring ADL assistance. Record reviews with SS staff showed no documentation of any care conferences for either resident, and SS confirmed that none were held. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires resident participation in person-centered care planning or documented reasons and efforts when participation is not practicable.
The facility did not ensure residents were involved in decisions about their restorative and therapy services when frequencies and durations were reduced. One resident with diabetes and paraplegia, who had intact cognition and required assistance with ADLs, had an AROM program reduced from six to three sessions per week and reported not being informed of the change or the shortening of sessions. Another resident with post-stroke left-sided weakness, lung disease, and HTN had an AROM program similarly reduced, while the resident’s representative stated they had been told at a care conference that services were being provided daily and were not informed of any changes. These actions were inconsistent with the facility’s policy requiring resident participation in person-centered care planning, including changes to the type, amount, frequency, and duration of care.
A resident with post-stroke hemiplegia, aphasia, and DM with ketoacidosis was admitted for short-term care, with the daughter identified as the responsible party. Social services staff documented voicemail and phone contact to invite the responsible party to a care conference and noted that the party would attend by phone, but there was no follow-up documentation confirming that the conference occurred with the representative’s participation. An IDT conference note later indicated a care conference was held with SSD, ADON, and DOR, but the Nursing Services section was left incomplete and there was no record that the representative was involved. The MDSC confirmed the resident was nonverbal, tube-fed, and bedbound, that SSD schedules conferences within the first week of admission, and that there was no documentation of contact with the representative, contrary to facility policy requiring resident/representative participation and documented notification for care planning.
A resident with severe cognitive impairment, failure to thrive, severe protein-calorie malnutrition, and advanced kidney disease had a designated health care power of attorney, but the facility failed to involve this representative in care planning. The representative reported being unaware of the resident’s significant weight loss and observed the resident eating without needed assistance, prompting concerns about dietary care, pain, and poor communication. Progress notes indicated that staff told the representative a care conference would be held to discuss possible hospice and end-of-life care, but the DON later confirmed there was no follow-up and no care conference occurred, and the resident was not receiving hospice or end-of-life services.
A resident’s responsible party (RP), who works full time as a physician, was notified by voicemail on the morning of a scheduled interdisciplinary care conference that the meeting would occur later that same day, leaving him unable to attend. The SSA documented only that a message was left and acknowledged typically not charting returned calls, while the care conference proceeded with staff present and the RP noted as invited but not attending. The RP reported ongoing difficulty having calls returned, trouble getting conferences scheduled at times he could attend, and not being kept informed of the resident’s care and treatment, despite facility policy stating that residents and their representatives are encouraged to participate in care planning and that meetings should be scheduled at times suitable for the resident and family.
Failure to Involve Resident and Representative in Person-Centered Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident the opportunity to participate in the development and implementation of a person-centered care plan. The resident had diagnoses of heart failure and respiratory failure, severe cognitive impairment, spoke Hmong, and was dependent for all cares and transfers. Her care plan identified her as a fall risk with a fall mat at the bedside and required assistance with eating, bed mobility, and transfers using two staff and a full body mechanical lift. However, the electronic medical record lacked documentation of any care conference since her admission, despite facility policies and staff statements indicating that care conferences should occur within 5–21 days of admission and then quarterly, with resident and/or representative participation. Surveyors observed the resident seated on the edge of a floor mattress with her breakfast tray placed on the mattress to her left. She was leaning on her left elbow and using her right hand to eat, with food falling onto the mattress as she tried to eat. Nursing assistants reported that the resident frequently crawled off her bed onto the floor mattress and that staff only placed her in a wheelchair when family were present to watch her. They also stated that she received bed baths instead of showers because it would take up to three staff to shower her, and one nursing assistant commented that some cultures, like Hmong, like to be on the floor, and was unsure whether eating on the floor bothered the resident. The social services director, clinical leader/LPN, DON, and administrator each confirmed that care conferences are intended to elicit resident preferences, discuss medications, cares, comfort, complaints, and ensure needs are met, and that such a conference should have been held for this resident within the required timeframe. They acknowledged that no care conference had been held and no documentation could be located. The resident’s family member stated she was never offered a care conference and, while agreeing with the use of a floor mattress for safety, expressed dissatisfaction that the resident was left on the floor mattress for hours, preferred that the resident be offered the toilet or commode, preferred showers instead of bed baths, and stated it was not their culture to eat on the floor. Facility policies on Resident Rights and Care Planning required that residents be informed of and supported in their right to participate in person-centered care planning, including incorporating personal and cultural preferences, which did not occur for this resident.
Failure to Conduct Care Conferences and Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure residents were allowed to participate in the development and implementation of their person-centered plans of care by not conducting required care conferences. For one resident with chronic viral hepatitis C, polyneuropathy, dementia, manic episode without psychotic symptoms, bipolar disorder, depression, and venous insufficiency, record review showed admission and subsequent discharge against medical advice with no guardian at the time of discharge. The most recent MDS 3.0 assessment documented moderately impaired cognition with varying levels of assistance needed for ADLs, and a later BIMS score of 13 indicated the resident was cognitively intact. Review of this resident’s medical record with Social Services staff revealed no evidence of any care conferences, and the Social Services staff member confirmed that none had been conducted. For another resident with diagnoses including mood disorder, bipolar disorder, cauda equina syndrome, catatonic schizophrenia, and major depressive disorder, the most recent MDS assessment showed severely impaired cognition and a need for assistance with ADLs. Review of this resident’s medical record with Social Services staff likewise revealed no documentation of any care conferences, and the Social Services staff member verified that none had been held. The facility’s Comprehensive Care Plans policy states that each resident’s comprehensive person-centered care plan must be consistent with the resident’s right to participate in the planning process, and that if resident or representative participation is not practicable, an explanation and the steps taken to include them must be documented in the medical record. Such documentation was not present for these residents. This deficiency was cited under Complaint Number 2691577.
Failure to Involve Residents in Changes to Restorative Care Plans
Penalty
Summary
The facility failed to ensure residents were provided the opportunity to participate in decisions about their care and treatment, specifically related to restorative nursing and therapy services. Facility policy dated 03/2022 stated that residents had the right to participate in the development and implementation of their comprehensive person-centered care plan, including determining the type, amount, frequency, and duration of care, receiving the services in the care plan, and seeing and signing the care plan after significant changes. For one resident with diabetes, paraplegia, and depression, whose comprehensive assessment showed intact cognition and a need for partial to maximum assistance with ADLs, the medical record documented a restorative nursing AROM program at a frequency of six times per week. The care plan, initiated on 10/30/2025, was later modified on 03/05/2026 to reduce the AROM frequency to three times per week. During interview, this resident reported frustration about the change in therapy services, stating they were not informed of the reduction from six to three days per week and that session length had been cut from 30 minutes to 20 minutes. A second resident, with left-sided weakness/paralysis after a stroke, lung disease, and hypertension, was assessed as dependent on one to two staff for ADLs and having moderately impaired cognition. This resident’s care plan showed an AROM program initiated at six times per week, which was also reduced to three times per week on 03/05/2026. In an interview, the resident’s representative stated that at a recent care conference they were told the resident was receiving restorative nursing services every day, but they did not know if that was occurring and were not informed of any changes in services. These findings showed that changes in restorative/AROM frequency and duration were made without informing or involving the residents or their representative as required by the facility’s person-centered care planning policy.
Failure to Involve Resident Representative in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident representative was involved in the development and implementation of a person-centered care plan when a scheduled care plan conference was not conducted as planned. The resident was admitted in mid-January 2026 with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and type 2 diabetes mellitus with ketoacidosis. The admission record identified the resident’s daughter as the responsible party (RP). An IDT note dated 1/19/26 by Social Services Assistant (SSA) 1 documented a voicemail left for the RP requesting a return call. A social service note dated 1/20/26 by SSA 2 documented that the RP was called and asked to attend a care conference at 2:30 p.m. and that the RP would participate over the phone. There was no subsequent social services documentation confirming that the care conference occurred or that the RP participated. An IDT conference note initiated 2/5/26 stated that a care conference was conducted that day with the Social Services Director (SSD), Assistant DON (ADON), and Director of Rehabilitation (DOR), and that the resident planned to discharge home with support; this note was signed by SSA 1 on 2/18/26. SSA 2 later stated she did not know if the RP attended the care plan conference, and SSA 1 stated that SSD 1 had created the IDT care conference note on 2/5/26 and that she completed it on 2/18/26 because SSD 1 had not finished her notes. The Minimum Data Set Coordinator (MDSC) confirmed that the SSD schedules care plan conferences, that the conference should be done within the first week of admission, and that the resident was nonverbal, on tube feeding, and bedbound. The MDSC acknowledged that the IDT conference note for this resident had sections completed by Dietary, Therapy, Activities, and Social Services, but the Nursing Services section was not filled out and there was no documentation that Social Services had spoken with the resident’s representative. The facility’s policy stated that residents and/or representatives are encouraged to participate in care plan development and that the SSD or designee is responsible for notifying them and maintaining records of such notices, including input if they are unable to attend.
Failure to Involve Resident Representative in Care Planning and Hospice Discussion
Penalty
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).
Insufficient Notice to Responsible Party for Care Plan Conference
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient notice to a resident’s responsible party (RP) to allow participation in the development and implementation of a person-centered care plan. The resident’s son, who is the RP and a full-time working medical doctor, reported that he received a voicemail from the facility on the morning of 11/13/25 informing him that a care planning conference was scheduled for later that same day. Due to the short notice, he was unable to attend. He also stated he had ongoing difficulty getting his calls returned by facility staff and had been unsuccessful in the past in getting care conferences scheduled at times he could attend, and that he was not kept informed of the resident’s care and treatment. Interviews and record reviews showed that the Social Service Assistant (SSA) called the RP on the morning of 11/13/25, left a message, and documented in a Social Service Progress Note that there was no answer and a message was left requesting a return call. The SSA stated that returned calls were usually not documented in the chart. A Progress Note from later that same day documented that an Interdisciplinary Care Conference was held, listed the staff attendees, and indicated that the son/RP was invited by phone but did not attend, and that a copy of the care plan was refused by the resident/resident representative. The Social Services Director acknowledged that calling the RP on the same day as the care conference was short notice. The facility’s care planning policy stated that residents and their representatives are encouraged to participate in care plan development and that every effort will be made to schedule care plan meetings at the best time for the resident and family.
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