Incomplete Documentation of Resident Care Conferences
Penalty
Summary
The facility failed to maintain complete and accurate documentation for three residents, identified as R44, R62, and R65. Each resident had scheduled care conferences that were not documented in their clinical records as having been performed. Resident R44, admitted in 2015, had a care conference scheduled for February 2025, which was not documented. Similarly, Resident R62, admitted in 2021, and Resident R65, admitted in 2020, both had care conferences scheduled for February 2025, which also lacked documentation in their records. During an interview, Social Services Employee E10 confirmed that the care conferences for these residents did occur in February 2025, but the documentation had not been entered into the medical records. Employee E10, who took over as the primary Social Worker in January, admitted to being behind on documentation. This oversight resulted in the facility's failure to maintain complete and accurate records as required by regulations.
Plan Of Correction
The facility cannot correct the documentation omission regarding care conferences for R 44, R62, and R65. Care conference schedule developed. Moving forward, it will be audited for compliance. To prevent this from happening again, DON/designee educated Social Services on the regulatory requirements of F842 and maintaining complete and accurate documentation. To monitor and maintain ongoing compliance, the DON/designee will audit care conferences to ensure they are occurring as scheduled and documented in the medical record. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.