Failure to Conduct Timely and Comprehensive Care Plan Reviews
Penalty
Summary
The facility failed to prepare and maintain comprehensive care plans for two residents, as required. Specifically, the care plans were not reviewed and revised quarterly following each assessment, and the participation of the residents and their representatives was not consistently included to the extent practicable. For one resident with severe cognitive impairment and a history of muscle wasting, urinary tract infections, and mild cognitive impairment, quarterly care plan reviews were missed in two out of five required periods. For another resident with epilepsy, a history of falls, and hypertensive heart disease, three out of six quarterly care plan reviews were missed. Interviews revealed that the residents' representatives were not regularly involved in care plan meetings, with one stating she could not recall recent participation and another having to request a meeting. The Director of Social Services acknowledged that care plan review meetings were missed and attributed this to a lack of a formal schedule, stating that she was attempting to catch up on overdue assessments. The facility's policy indicated that the MDS Coordinator was responsible for scheduling and preparing the care plan meeting calendar, but no updated policy on regular care plan meetings was provided upon request. The DON and Administrator confirmed that issues with the regularity of care plan meetings had been identified previously. Documentation showed that the facility had discussed care plan meeting processes in a QAPI meeting, but gaps in care plan reviews persisted for the residents involved.