Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that care conferences were conducted and care plans were updated in a timely manner for multiple residents, as required by policy and regulation. Medical record reviews, interviews, and incident reports revealed that several residents did not have care conferences scheduled or rescheduled within the required timeframes, particularly when residents were unavailable or out of the facility. In some cases, care conferences were missed for entire quarters, and documentation confirmed that these were not rescheduled at the earliest convenience, as verified by staff interviews. Additionally, the facility did not consistently update care plans when new interventions were implemented following incidents such as falls. For example, after a resident experienced multiple falls, immediate interventions like non-skid socks and pharmacy reviews were initiated but not promptly or accurately reflected in the resident's care plan. In some instances, interventions were back-dated in documentation to appear as though they were implemented earlier than they actually were. Interviews with the DON confirmed that certain interventions were not added to the care plan until much later, despite being put in place following incidents. Residents affected by these deficiencies had a range of complex medical conditions, including cognitive impairments, neurological disorders, and chronic diseases. Family members and residents reported a lack of communication regarding care conferences, with some stating they had not participated in or been informed about care planning meetings for extended periods. Staff interviews corroborated that care conferences and care plan updates were not completed as required, impacting the facility's ability to provide coordinated and individualized care.