F0657

E

Failure to Conduct and Document Required Initial and Quarterly Care Plan Conferences

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct and document initial and quarterly care plan conferences with residents and/or their representatives as required by regulation and facility policy. The facility policy states that patient care conferences are to be held within seven days of admission, upon significant change, and quarterly thereafter, with the interdisciplinary team developing a comprehensive, person-centered care plan in conjunction with the resident and family or legal representative. For multiple residents, surveyors found missing or significantly delayed care conferences despite completed MDS assessments and intact cognition, and the Social Service Director confirmed that required conferences were not held.

For one resident with diagnoses including moderate protein malnutrition, cystic fibrosis, ALS, anxiety, gastrostomy, chronic pain syndrome, major depression, and functional quadriplegia, records showed care conferences only on 02/10/25 and 10/15/25, with no evidence of quarterly conferences in between. Another resident with diabetes, morbid obesity, adult failure to thrive, COPD, chronic respiratory failure, asthma, schizoaffective disorder, anxiety, depression, personality disorder, and PTSD had intact cognition and required varying levels of ADL assistance, yet there was no documented evidence of any plan of care conferences. The Social Service Director verified that quarterly care conferences were not held for these residents.

Additional residents were similarly affected. One resident with protein calorie malnutrition, COPD, peripheral vascular disease, and atherosclerosis with leg ulceration had care conferences documented only on 02/05/25 and 04/11/25, with no further quarterly meetings. Another resident with type 2 diabetes, a right below-knee amputation, moderate protein-calorie malnutrition, and chronic kidney disease had intact cognition, but there was no evidence of any care conferences; the resident reported never attending a care conference, and the Social Service Director stated conferences were not done due to the resident’s inappropriate sexual behaviors and inability to reach family, without documentation of attempts or explanations as required by policy.

One resident admitted with acute on chronic diastolic heart failure, ulcer of anus and rectum, and type 2 diabetes had an admission care conference, during which the resident requested that the wife not be notified; however, no quarterly care conferences were completed afterward, despite an MDS showing intact cognition. The resident stated they were not aware of any care conferences being held. Another resident with malignant carcinoid tumor of the stomach, severe protein-calorie malnutrition, type 2 diabetes, and vascular dementia, with severe cognitive impairment and a son listed as emergency contact, had no evidence of an initial care conference with either the resident or responsible party. The Social Service Director confirmed there was no initial care conference and could not explain why.

A further resident with acute and chronic respiratory failure with hypoxia and hypercapnia, obstructive sleep apnea, and morbid obesity with alveolar hypoventilation had intact cognition and required assistance with ADLs, with documentation that the resident rejected care on some days. The medical record contained no indication that a care conference had been conducted or attempted. The resident reported not being asked to participate in care plan meetings, expressed a desire to go home, and stated dislike of social work interactions, indicating no opportunity to engage in the care planning process. The Social Work Director confirmed there was no documentation of a care conference, acknowledged only a verbal discussion about a potential conference months earlier, and no subsequent attempts or documentation, contrary to the facility’s comprehensive person-centered care plan policy requiring conferences and documentation of refusals or impracticability.