Missed Quarterly Care Conference for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to conduct a required quarterly care conference for one resident who was admitted with major depressive disorder and early-onset Alzheimer's disease. The resident's medical record indicated severe cognitive impairment, as evidenced by a score of 0 out of 15 on the Brief Interview for Mental Status (BIMS). Documentation showed that the last care conference was held in December, and the next was due in March but was not conducted. Family reported inconsistencies with care conferences, and staff confirmed that the conference was missed due to the recent loss of the facility's social worker, resulting in delays in scheduling and documentation.
Plan Of Correction
F657 – Care Plan Timing and Revision Element #1: Social worker held a quarterly care conference for R33 on 05.12.2025. Element #2: The Social Service Director conducted a 100% audit of residents to ensure care conferences are held timely and per policy. Element #3: The Administrator reviewed the regulation F657. Licensed Nurses and Department Managers were provided education on the regulation and its guidelines. Element #4: The Social Service Director will conduct weekly audits of 5 residents to ensure their care conferences have been scheduled and held per regulatory guidelines. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025