Deficient Care Planning and Care Conference Practices
Penalty
Summary
The facility failed to ensure timely and appropriate care planning and care conference practices for two residents. For one resident with diagnoses including schizophrenia, diabetes, and cognitive communication deficit, the nutritional care plan had not been updated or revised for over two years, despite a significant weight loss of more than 20 pounds (12.22%) over six months. The care plan interventions remained unchanged, only including monitoring for weight loss and making diet recommendations as needed. Progress notes showed a lack of documentation regarding nutrition for nearly a year, and although the resident's weight loss was eventually noted and determined to result in a healthy BMI, no new interventions were added or adjusted in the care plan following this significant change in nutritional status. For another resident with heart failure, PVD, renal insufficiency, and diabetes, care conferences were not held in a timely manner and lacked appropriate interdisciplinary team (IDT) participation. The only documented care conference was conducted late and attended solely by a social worker assistant. There was no documentation of care conferences being conducted with the resident or other IDT members, and the resident reported not receiving a care conference on admission or quarterly. The social worker assistant confirmed the delay and lack of documentation, as well as the practice of not inviting IDT members if the resident did not request their presence.