Failure to Complete and Document Required Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were completed quarterly for two residents, as required by both facility policy and regulatory standards. For one resident with diagnoses including diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility, there was no documentation of care plan meetings following quarterly and annual Minimum Data Set (MDS) assessments. The Director of Nursing (DON) confirmed that these meetings should have occurred but were not documented in the clinical record. Similarly, another resident with gastrostomy status, type 2 diabetes mellitus with diabetic chronic kidney disease, and diverticulosis of the large intestine had an admission care plan conference documented, but no subsequent quarterly care plan meetings were recorded after later MDS assessments. The DON acknowledged that required quarterly care plan meetings had not been conducted for this resident. Facility policy specifies that care plan meetings should be held at least quarterly and with significant changes, but this was not followed for the residents reviewed.