Failure to Complete Required Resident Care Conferences and 72-Hour Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to complete Resident Care Conferences (RCCs) within required timeframes, including 72-hour admission conferences and at least quarterly reviews, as required by facility policy and regulatory expectations. For a resident with mild cognitive impairment, dysthymic disorder, left foot drop, and moderate protein calorie malnutrition, the record showed a care plan meeting held in early May 2025 with the resident and conservator, but no subsequent RCCs were scheduled or held from early May 2025 through mid-January 2026. Following a quarterly MDS dated in mid-January 2026, which documented intact cognition (BIMS 15) and dependence on staff for personal hygiene, bed mobility, and transfers, there was no evidence of an RCC being scheduled or held through the resident’s discharge in early February 2026. Another resident with Alzheimer’s disease (late onset), age-related macular degeneration, and major depressive disorder had an RCC documented in late September 2025 with the conservator present, but the record contained no evidence of any subsequent RCC being scheduled or held after a quarterly MDS completed in early December 2025, despite the MDS showing severely impaired cognition (BIMS 4) and dependence on staff for bed mobility and transfers; an RCC signature sheet for this resident was not available. A third resident with major depressive disorder, chronic kidney disease, and generalized abdominal pain had a quarterly MDS indicating intact cognition (BIMS 15) and independence with bed mobility, transfers, and ambulation, yet the clinical record from admission in mid-May 2025 through early March 2026 showed no 72-hour care plan meeting or any RCC scheduled or held, and no RCC signature sheet was obtained. The DON stated that RCCs should occur within 72 hours of admission and at least quarterly, and the Director of Social Services reported that staffing challenges contributed to inconsistent completion of 72-hour, change-in-condition, and quarterly RCCs, contrary to the facility’s Person-Centered Care Plan policy requiring invitations and documentation of care plan meetings via a Care Plan Meeting note.
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