Failure to Offer Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to participate in care conferences and that care plans (CPs) were updated as needed, as required by facility policy and regulatory standards. Specifically, two residents who were cognitively intact and able to communicate did not recall being invited to or participating in care conferences following significant assessment updates or admission. Record reviews confirmed that care conferences were either not documented or not held as required, and staff interviews acknowledged these omissions. Additionally, the facility did not update or revise care plans to reflect changes in residents' conditions or treatments. One resident's care plan continued to include goals for splint use even after the splint was discontinued due to repeated refusals, and another resident's care plan inaccurately described the type of urinary catheter in use, despite physician orders and direct observation confirming the presence of an indwelling catheter. Staff confirmed that these care plans were not accurate or current, contrary to expectations and policy.