Failure to Conduct Interdisciplinary Care Conferences with Resident and Representative Involvement
Penalty
Summary
The facility failed to conduct care conferences with the required participation of the resident, their representative, and the full interdisciplinary team (IDT) for multiple residents. Documentation and interviews revealed that care conferences were routinely attended only by the Resident Care Manager (RCM) and Social Services staff, with other vital IDT members such as nursing, therapy, dietary, and activities staff not present. In several instances, care conference forms were completed by different staff members on separate dates, rather than as a collaborative team meeting with the resident and their representative. Residents reported not being included in their care planning process and not receiving care conferences that involved all relevant departments. For example, one resident stated they had not had a care conference with nursing, therapy, social services, dietary, and activities, and had not received a copy of their care plan. Another resident expressed that their power of attorney or representative was not involved in their care planning, despite being listed in their records. These findings were corroborated by staff interviews, which confirmed that only limited staff attended care conferences and that other departments, though invited, did not participate. Record reviews showed that care conferences were not completed within the required timeframes, such as within 72 hours of admission, and that resident representatives were not invited as required by facility policy and admission agreements. The lack of full IDT participation and resident or representative involvement in care conferences was observed for several residents, including those with complex medical needs such as tube feeding, neurological disorders, and recent admissions requiring therapy services.