Failure to Hold Timely Care Plan Meetings and Update Care Plans After Changes in Condition
Penalty
Summary
Facility staff failed to conduct timely quarterly care plan meetings and did not update care plans following changes in residents' conditions. For one resident admitted in June 2024, there was only one documented care plan meeting since admission, despite quarterly MDS assessments being completed. The Director of Nursing confirmed that required quarterly care plan meetings were not held for this resident until nearly a year after admission. Another resident experienced multiple falls, including an unwitnessed fall resulting in a left humerus fracture, but the care plan was not updated with new interventions after these incidents. The Director of Nursing acknowledged that the care plan should have been revised to include additional fall prevention measures. Additionally, for a third resident, there were significant gaps in social work documentation and care plan meetings, with periods where no meetings were held and instances where required staff or family participation was lacking. The Social Work Assistant confirmed the absence of a full-time social worker and irregular care plan meeting practices.