Failure to Document and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to provide and/or maintain timely documentation of care conferences for two of three sampled residents during care planning review. For one resident with diabetes and high blood pressure, there was no evidence in the electronic health record (EHR) that a care conference had occurred following admission, and the resident confirmed not having attended such a meeting. For another resident with heart failure, arthritis, and depression, although a social services progress note indicated a care conference was completed and was to be uploaded to the EHR, there was no documentation in the EHR to confirm this occurred, and the resident did not recall attending a care conference. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that care conferences had not been conducted or properly documented as required. Staff acknowledged that care conferences should have been held and documented within the initial assessment period and that the lack of documentation did not meet facility expectations. The absence of timely and documented care conferences was verified through both resident interviews and EHR review.