Failure to Hold and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held at least quarterly and that follow-up on concerns raised during these conferences was documented for a resident with a diagnosis of depression and intact cognition. The resident's Minimum Data Set (MDS) indicated that having family or a close friend involved in care discussions was very important. While the electronic health record showed a care conference note with family and the resident in attendance on one occasion, there was no documentation of any care conferences held over a six-month period. Both the electronic and paper records lacked evidence of care conferences or follow-up on concerns discussed during this time. Interviews with the resident revealed dissatisfaction with the care conference process, stating that concerns raised were not addressed. Staff interviews confirmed that the MDS nurse was responsible for arranging care conferences but none were held during her tenure, and there was no policy in place for care conferences. The administrator and regional clinical director acknowledged the absence of care conference records and documentation, and confirmed that the facility was not in compliance with the requirement to hold and document quarterly care conferences.