Failure to Complete and Document Timely Care Plan Conferences
Penalty
Summary
The facility failed to complete and document comprehensive care plans and conduct interdisciplinary care conferences for three sampled residents, as required by regulatory guidelines. Record reviews for these residents showed an absence of care plan meeting notes, care conference summaries, or care plan acknowledgment forms over the past six months. Interviews with residents confirmed that they had not participated in care plan conferences for an extended period, and staff interviews corroborated that care conferences were behind schedule and not consistently documented. For one resident, the Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment and a primary diagnosis of Multiple Sclerosis, yet there was no evidence of care plan meetings or documentation. Another resident, also with Multiple Sclerosis and a high cognitive function score, similarly lacked documentation of care plan conferences. A third resident, who was cognitively intact, had some care plan meetings documented, but there were missing records for required quarterly and annual conferences, and the resident reported no involvement or awareness of such meetings. Staff interviews revealed that there was no current system for scheduling care plan conferences, and notifications to families were not consistently sent in a timely manner. The facility's electronic health record system was intended to trigger the care plan process, but this was not reliably followed. Additionally, there was no facility policy on care planning, and the social services staff did not have a process for tracking care conferences, contributing to the ongoing deficiency.