Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences with residents and their families, as required, for three residents reviewed. One resident, who was cognitively intact, had a care conference documented in January, but no subsequent conference was held as scheduled in April. The resident confirmed that it had been months since her last care conference. Another cognitively intact resident had a care conference upon admission in November, but no further conferences were documented or held as scheduled in February. This resident also reported not having another care conference since admission. A third resident, who was severely cognitively impaired, had no care conferences documented in the medical record. The resident's representative, who held Power of Attorney, reported not receiving any invitation to participate in a care conference. Staff interviews revealed confusion regarding responsibility for scheduling and conducting care conferences, with the former Social Worker stating she was unaware it was her duty and was unable to catch up once informed. The Administrator and Nurse Consultant confirmed that the Social Worker had been responsible for care conferences, but after her termination, a review of resident charts revealed that many care conferences had not been completed. An audit identified that a significant number of residents were missing documented quarterly care plan meetings, indicating a systemic failure to ensure resident and representative participation in the care planning process.