Failure to Provide Routine Care Conferences and Interdisciplinary Care Plan Review
Penalty
Summary
The facility failed to provide routine care conferences for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including major depressive disorder, Alzheimer's disease, unspecified psychosis, and dementia. Documentation showed that the last care conference was held on 10/7/24, with a subsequent entry on 6/24/25, indicating a significant gap in the expected quarterly schedule. The resident's family member reported that care conferences were initially held quarterly but were discontinued after the social worker left the facility, and no further conferences were offered. The family member expressed a desire to participate in care conferences and contribute to the resident's care plan. Interviews with facility staff, including an LPN manager, the director of social services, and the DON, confirmed that the expectation was to hold care conferences quarterly, annually, upon admission, with changes in condition, or upon request. The interdisciplinary team (IDT), including family, dietary, therapy, social services, nursing, and administration, was expected to be informed and participate. Facility policy also required care conferences to be conducted after admission, quarterly, for discharge planning, changes in condition, or as needed. Despite these policies and expectations, the facility did not provide the required routine care conferences for the resident, resulting in a lack of interdisciplinary review and family participation in the care planning process.