F0842

D

Missing Quarterly Care Conference Documentation in EMR

Houston, Texas Survey Completed on 12-03-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurately documented clinical records for a resident, specifically the absence of a required quarterly care conference report in the EMR. The resident was an adult female with multiple significant diagnoses, including hemiplegia, bladder disorder, COPD, atherosclerotic heart disease, anemia, lack of coordination, osteoporosis, major depressive disorder, generalized weakness, gait and mobility abnormalities, dysphagia, oropharyngeal cancer, and cognitive communication deficit. Her MDS dated 09/14/2025 showed she was cognitively intact with a BIMS score of 15, used a wheelchair, and required assistance with ADLs. Her care plan indicated that a care conference was held on 06/10/2025 and that the next conference was due on 09/10/2025.

Record review of the resident’s care conference reports showed documentation only for conferences held on 03/11/2025 and 06/10/2025, with no documentation of a care conference or assessment for the due date in September 2025. The facility’s own records and MDS coding reflected that care conferences were to be conducted quarterly, yet there was no care conference report in the EMR for the September interval. Multiple staff interviews confirmed that care conferences were expected every three months for each resident and that the resident’s schedule would have been June, September, and December. Staff also consistently stated that, from a nursing standpoint, if something was not documented, it was considered not to have occurred.

Interviews with the MDS Coordinator, SW, AD, DON, ADON, and Administrator established that the MDS Coordinator was primarily responsible for taking notes during care conferences and uploading the minutes into the EMR, with the DON or ADON serving as backups when the MDS Coordinator was absent. The MDS Coordinator acknowledged responsibility for uploading the minutes but could not explain why the September care conference report was missing. The SW, AD, DON, and ADON all confirmed that care conferences were held quarterly, listed typical attendees, and stated that the EMR should contain the notes as proof that a conference occurred. The DON suggested the missing September record could be due to human error and noted she was newly hired and multitasking at the time, while the ADON stated there was no documentation for September because the DON missed documenting. The facility’s care planning policy required person-centered care plans developed by an interdisciplinary team within specified timeframes and documentation in the medical record when participation was not practicable, but the September care conference documentation for this resident was not present in the EMR.

The facility’s written policy on care planning and interdisciplinary team (IDT) care area assessments specified that residents’ care plans are developed according to timeframes, are person-centered, and are created by an IDT including nursing, food and nutrition services, and the resident or representative. It also required that if resident or representative participation is not practicable, an explanation must be documented in the medical record. Despite these requirements, there was no documentation in the EMR to show that the September quarterly care conference for this resident occurred, nor any explanation for lack of participation or rescheduling. Staff interviews repeatedly emphasized that the EMR should be the source to verify whether a care conference was conducted and that missing documentation meant the conference was not done, thereby demonstrating that the facility failed to maintain clinical records in accordance with accepted professional standards and practices for this resident.

The Administrator confirmed that care conferences were completed quarterly and that, based on the June date, the next conferences should have been in September and December, and also confirmed that the MDS Coordinator was responsible for uploading the conference reports into the EMR. However, no September care conference report was found in the EMR for this resident during the surveyor’s review. This combination of record review, staff statements, and facility policy established that the facility did not maintain a complete, accurately documented, and systematically organized clinical record for the resident’s September quarterly care conference, resulting in the cited deficiency.