Failure to Hold Required Quarterly Care Planning Meetings
Penalty
Summary
The facility failed to hold quarterly care planning meetings for three residents reviewed for care planning and restraints. For one resident with hypertensive heart disease, chronic kidney disease, and heart failure, the clinical record showed that the last documented care conferences were held in the previous year, with no further documentation for the current year. The resident, who was cognitively intact and dependent for personal hygiene and ADLs, reported not having been involved in a care planning meeting for a long time, though could not specify the exact timeframe. The care plan was revised, and a physician's order directed care as outlined in the plan, but required care conferences were not documented as held. For two other residents, one with gastrointestinal hemorrhage, dysphagia, and hemiplegia, and another with hereditary spastic paraplegia, depression, and dysphagia, similar deficiencies were observed. Both residents were dependent for all personal care and ADLs, and required tube feedings with monthly dietician evaluations. Their records showed that after initial care conferences, no further quarterly care conferences were documented for the current year. Interviews with facility staff confirmed that care conferences should be held quarterly after the MDS is completed, and a change in social workers may have contributed to the missed meetings. Facility policy required care conferences at least quarterly, but this was not followed for the residents reviewed.