Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed and that residents or their representatives participated in the development and implementation of person-centered care plans. For three of four residents reviewed, there was no evidence of required care conferences being held, including upon admission and quarterly as mandated. One family member reported ongoing concerns about a resident's need for an eye doctor appointment and new glasses, stating that despite repeated communication with the social worker, no action was taken by the facility, leading the family member to arrange the appointment independently. The same family member also expressed concerns about not being notified in a timely manner regarding medication changes and falls. Review of electronic medical records confirmed the absence of documentation for care conferences for multiple residents, with staff interviews corroborating that care conferences were not held as required and that the responsibility for organizing them had shifted between staff members. The social worker, DON, and NHA all acknowledged that care conferences were not conducted regularly, and that not all interdisciplinary team members attended when they did occur. The lack of care conferences and documentation affected all residents in the facility.