Failure to Hold and Document Required Care Plan Meetings with Resident Participation
Penalty
Summary
The facility failed to ensure that care plan conference meetings were held on admission and quarterly for two residents, as required by both facility policy and federal and state standards. Facility policy mandates that a care plan meeting be held within seven days following a new comprehensive assessment and that these meetings be reviewed and updated at least quarterly, with the resident and/or their representative invited and encouraged to participate. Documentation of the meeting, including participant names and roles, is required, and if the resident or representative chooses not to participate, this must be documented. However, for one resident with diagnoses including traumatic subarachnoid hemorrhage, convulsions, cerebral infarction, and pain, there was no documentation that care plan meetings were held or that the resident or representative was invited following multiple MDS assessments, despite varying levels of cognitive function as indicated by BIMS scores. The care plan for this resident was last reviewed and revised on 9/15/2025, but required documentation for prior meetings was missing. Similarly, another resident with fractures of both femurs and seizures was admitted and had an admission MDS assessment indicating moderate cognitive impairment. The facility was unable to provide documentation that a care plan meeting was held or that the resident or representative was invited following the admission assessment. The care plan for this resident was also last reviewed and revised on 9/15/2025. During an interview, the Interim DON confirmed that she could not provide documentation for the required care plan meetings for either resident and acknowledged that a care plan meeting had not been scheduled or completed for the second resident.