Failure to Complete and Document Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed as required for two residents. For one resident with diagnoses including major depressive disorder with psychotic symptoms and myotonia congenita, care conferences were only documented on three occasions, with a significant gap between two of the conferences. The resident, who had intact cognition, recalled only one care conference in the past year. The Director of Social Services confirmed that there was no evidence of additional care conferences during the required intervals, and facility policy required care planning discussions to be available as directed by federal and state guidelines. For another resident with multiple diagnoses including psychotic disorder, dementia, and Parkinson's disease, the medical record showed only two care conferences in the previous year, with one listed as "in process" and not completed. The most recent care conference documentation was incomplete, with several required sections left blank, including code status, nursing needs, and dietary services. The Social Services Director acknowledged the lack of completed documentation and missing care conferences for the required periods. Facility policy required that care planning discussions and documentation be completed as required by regulations.