Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to conduct timely and comprehensive care conferences and to update care plans as required, resulting in deficiencies in person-centered care for several residents. For three residents, there was no evidence that care conferences were held quarterly or upon admission, as required by facility policy. One resident reported not having a care conference for nearly nine months, and another did not recall any care plan meeting since admission. Documentation for these residents lacked input from all relevant departments, such as therapy, dietary, and nursing, and did not address all aspects of their care needs and preferences. Additionally, the facility did not ensure that care plans were updated and revised as needed for two residents. In one case, a care plan revision following a fall did not specify the frequency of range of motion checks or neurological assessments, leaving staff without clear guidance on the resident's care requirements. Staff interviews confirmed that care conferences and care plan updates were not consistently documented or conducted according to policy, and that these processes are essential for ensuring all departments and the resident are informed and able to address concerns. The residents involved had complex medical histories, including recent admissions with conditions such as hip fractures, malnutrition, major infections, and wounds. Despite being cognitively intact and able to participate in care planning, these residents were not provided with the opportunity to engage in care conferences or have their care plans updated to reflect their current needs. Facility policy required resident and representative participation in care planning, with advanced notice and documentation, but these procedures were not followed.