Failure to Hold and Document Required Quarterly Care Plan Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were able to participate in the development and implementation of their person-centered plans of care through required quarterly care plan conferences. Facility policy dated 1/5/25 states that care plan review/conference will be conducted at least quarterly, be interdisciplinary, and provide an opportunity for resident and family discussion and input. For one resident admitted with cervical radiculopathy, adult failure to thrive, pulmonary hypertension, and depression, with a BIMS score of 15 indicating intact cognition, there was no documentation of any quarterly care conference from mid-2025 through early 2026. The resident reported that care conferences had been scheduled in April and July but that no one showed up, and that nothing had been scheduled since July. Review of the medical record and progress notes from 6/17/25 to 2/3/26 revealed no evidence of a quarterly care conference, and both the Social Services Designee and Director of Social Services confirmed they could not identify any such conference for this resident. A second resident, admitted with palliative care needs, chronic lymphocytic leukemia, heart failure, and COPD, had a quarterly MDS showing severe cognitive impairment with a BIMS of 7 and functional limitations requiring assistance with mobility, hygiene, eating setup, showering, bed mobility, and transfers. Review of this resident’s progress notes and medical record on 2/3/26 showed no documentation of any care conferences. The social worker responsible for care conferences and admissions stated that no care conferences had been completed for this resident to their knowledge and that they had not conducted any for this resident. The social worker was unable to provide any emails or notes indicating that care conferences had occurred. When interviewed, the resident did not recall any care conferences since admission and stated that family usually handled care discussions but had not mentioned any conferences recently. A third resident, readmitted with Alzheimer’s disease, type II diabetes mellitus, dementia, and anxiety disorder, was described by staff as confused and speaking only a non-English language. Review of this resident’s medical record showed no evidence of any care conference in the previous twelve months while the resident resided full time at the facility. The social worker responsible for care conferences and admissions stated that, to their knowledge, no care conferences had been completed for this resident and confirmed they had not conducted any. They were unable to provide any supporting documentation such as emails or notes about care conferences. When these findings were presented to facility leadership, including the DON, NHA, and Director of Operations, no additional information was provided to explain the absence of required care conferences for these residents.
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