Failure to Document Care Plan Conference in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed for clinical records. Specifically, there was no documentation of a care plan conference that was reportedly held for a male resident with multiple complex diagnoses, including systolic heart failure, a history of poliomyelitis, cognitive communication deficit, dysphagia, vascular dementia, and peripheral vascular disease. The resident was at risk for pressure ulcers and had multiple venous and arterial ulcers, as well as other open lesions. While the baseline care plan and an initial care plan conference were documented, there was no record of a subsequent care plan conference that staff members stated had occurred. Interviews with facility staff, including the LMSW, DOR, ADON, MDS nurse, DON, and ADM, confirmed that a care plan meeting took place but was not documented in the resident's medical record. Staff indicated that it was the responsibility of the MDS nurse or LMSW to document such meetings, and acknowledged the importance of recording the occurrence, participants, and any concerns discussed. The facility's policy required that all services provided, progress towards care plan goals, and changes in the resident's condition be documented in the medical record, but this was not followed in this instance.