Deficient Care Conference Scheduling and Care Plan Updates
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly and that the interdisciplinary team was present for all required residents. In several cases, care conferences were either not held as scheduled or lacked documentation of team participation and discussion. For example, one resident with severe cognitive impairment and multiple complex diagnoses had only one care conference documented, with no supporting notes or progress entries, and family interviews confirmed that quarterly meetings had ceased. Another resident did not have a care conference upon admission, and the only documented meeting lacked interdisciplinary team signatures. Additional residents also missed required quarterly care conferences, as verified by staff interviews and record reviews. The facility also failed to update and revise care plans in response to changes in residents' conditions or new physician orders. In multiple instances, interventions that were discontinued, such as 15-minute checks for elopement risk, were not removed from care plans. For residents with new or worsening conditions, such as the development of additional pressure ulcers or changes in mobility needs, care plans were not updated to reflect current interventions or the need for one-to-one supervision. In one case, a resident receiving hospice services did not have an updated hospice care plan or accurate documentation of current care needs. Further deficiencies were identified in the failure to incorporate new physician orders and recommendations into care plans. For example, orders for blood sugar monitoring and physician notification for abnormal results were not included in the care plan for a resident with diabetes. Similarly, nutritional interventions such as weekly weights and increased supplements were not added to the care plan for another resident. In one case, a resident's advance directive status was not updated in the care plan after a change to DNR Comfort Care. These findings were confirmed through interviews with nursing and administrative staff, who acknowledged that care plans should have been revised to reflect these changes.