Failure to Hold Regular Resident Care Conferences
Penalty
Summary
The facility failed to conduct regular care conferences for multiple residents, as required by their own policy and federal regulations. Medical record reviews, resident and staff interviews, and care conference summary reports revealed that care conferences were not held for five residents across several quarters. These residents had significant medical conditions, including chronic respiratory failure, morbid obesity, diabetes mellitus, quadriplegia, encephalopathy, epilepsy, and dependence on mechanical ventilation. Despite having intact or impaired cognition and being dependent on staff for activities of daily living, these residents and their representatives were not included in care planning discussions at the required intervals. Interviews with the Social Services Director and Regional Social Services Director confirmed that care conferences were missed for each resident during specific quarters, sometimes spanning multiple consecutive quarters. The facility's policy stated that residents and/or their representatives should be informed of and participate in care planning at regularly scheduled conferences, with documentation of their participation. However, the lack of these conferences meant that residents and their representatives were not given the opportunity to participate in or be informed about their care plans as required.