Failure to Hold and Document Required Care Plan Conferences
Penalty
Summary
The facility failed to ensure that care plan conferences were held and documented for four out of five residents reviewed for unnecessary medications. For each of these residents, clinical record reviews revealed significant gaps in the documentation of care plan conferences within the past year. Specifically, one resident with diagnoses including anxiety, osteoporosis, depression, and early-onset cerebellar ataxia, who was cognitively intact, had no documented care plan conference between May 2024 and February 2025. Another resident with anxiety, depression, and dementia with behaviors, also cognitively intact, lacked documentation of a care plan conference between August 2024 and May 2025. A third resident with dementia without behaviors, depression, epilepsy, and anxiety, who was severely cognitively impaired, had no documented care plan conference after September 2024. The fourth resident, diagnosed with psychotic disorder with hallucinations, vascular dementia with behaviors, and stroke, and who was cognitively intact, had no documented care plan conference after August 2024. Interviews with facility staff confirmed that care plan conferences are expected to occur quarterly and as needed, with documentation required in the clinical record. The facility's own Comprehensive Care Plan Policy, revised in March 2022, also specifies that care plan meetings should take place according to state regulations, including at admission, with changes in condition, quarterly, annually, or as requested by the resident, POA, or facility. Despite these requirements, the records for the identified residents did not contain evidence of timely care plan conferences, resulting in a failure to allow residents to participate in the development and implementation of their person-centered care plans.