Failure to Timely Update Care Plans and Conduct Care Conferences
Penalty
Summary
The facility failed to ensure timely completion of care conferences following significant change Minimum Data Set (MDS) assessments and did not revise care plans to accurately reflect residents' current conditions and interventions. For one resident, the care plan was not updated to reflect the acquisition and use of dentures, despite dental consults and the resident's own report confirming full upper and lower dentures. Staff interviews revealed confusion about the resident's dental status, with some staff unaware of the presence of dentures, and the care plan still indicating the resident was edentulous. Another resident experienced a significant change in condition, as documented by a completed MDS assessment, but there was no evidence that a care conference was held in a timely manner. The only care conference on record was the initial one completed at admission, with no subsequent conferences documented until a month after the significant change assessment. The facility's own policy requires care conferences to be held quarterly or upon significant changes, but this was not followed. Additionally, a third resident with a history of multiple skin tears had a care plan that included the use of geri-sleeves as an intervention. However, the resident was observed without geri-sleeves, and staff reported that the resident refused the intervention, leading to its removal from charting. Despite this, the care plan was not revised to address the resident's non-compliance with the intervention, and there was no documentation of alternative measures or updates to the care plan to reflect the resident's current status.