Failure to Conduct Quarterly Care Conferences and Revise Care Plans
Penalty
Summary
The facility failed to conduct and document quarterly care conferences for three residents and did not ensure care plans were revised as required for two residents. For one resident with diabetes, anxiety, and depression, there was no documentation of a care conference for over two and a half years, despite a note indicating the resident declined a quarterly conference at one point, with no evidence of further offers or follow-up. Another resident in a persistent vegetative state had only a single documented attempt to schedule a care conference with their representative, with no further follow-up. A third resident, who had no memory impairment, reported not being offered or having a care conference since admission, and records confirmed no such documentation except for a single declined offer, with no further attempts noted. Additionally, the facility did not revise care plans as required for two residents. One resident with respiratory failure had a care plan that continued to include oxygen supplementation and monitoring, even after supplemental oxygen was discontinued, which was not updated in the care plan and could cause confusion. Another resident with multiple complex diagnoses, including heart failure and risk for malnutrition, repeatedly refused to be weighed as ordered by the physician. The care plan for this resident did not include specific interventions to address refusals to be weighed, nor did it document staff efforts to obtain the resident's weight, despite ongoing refusals and the importance of weight monitoring for medication management. Interviews with facility staff confirmed that the process for providing quarterly care conferences was inconsistent and not fully implemented, with some disciplines no longer attending care conferences as expected. Staff also acknowledged that care plans were not always updated to reflect changes in residents' needs or to include specific interventions for care refusals, as required by facility policy and regulatory standards.