Failure to Complete Quarterly Care Conferences and Maintain Accurate, Updated Care Plans
Penalty
Summary
The facility failed to ensure that care conferences were completed at least quarterly for several residents, and did not maintain accurate or updated care plans for others. Specifically, three residents did not have documented evidence of quarterly care conferences, despite policy requiring these to be held in conjunction with the quarterly MDS assessment. Interviews with residents and staff confirmed that these conferences either did not occur or were not documented, and in some cases, residents were not invited to participate in their own care planning process. Additionally, the facility did not ensure care plan accuracy for a resident regarding incontinence care. The care plan inaccurately identified the resident as being incontinent of bowel and bladder and having an indwelling urinary catheter, when in fact the resident was continent and had never had a catheter. Interviews with the resident, an LPN, and the DON confirmed the inaccuracies in the care plan, and there was no explanation for why the care plan did not reflect the resident's actual condition. Furthermore, the facility failed to update the care plan for another resident after a significant change in condition, specifically following a fall that resulted in a major injury and subsequent hospitalization and surgery. Although immediate post-fall interventions were documented, the care plan was not revised to reflect the new risk or interventions after the resident returned from the hospital. Facility policy required care plans to be updated after significant changes or hospitalizations, but this was not done in this case.