Failure to Hold Quarterly Care Plan Conferences for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plan conferences were completed quarterly for six out of seven residents reviewed. For several residents, including those with diagnoses such as cerebral palsy, diabetes mellitus, major depressive disorder, dementia, repeated falls, wedge compression fracture, hypertensive encephalopathy, and hypertension, the most recent care plan conferences were either not held within the required quarterly timeframe or had not been conducted since admission. Clinical records showed that some residents had not had a care plan conference for several months, and in two cases, no care plan conference had been held since the residents were admitted. Interviews and record reviews confirmed that the facility's policy required residents and/or their representatives to be invited to participate in care plan conferences at least quarterly, either in person, by phone, or via video conference. However, documentation for recent care plan conferences was missing for multiple residents, and the Director of Nursing acknowledged that these conferences were supposed to be held quarterly. Requests for records of care plan conferences for certain residents could not be fulfilled, further confirming the deficiency.