Failure to Complete and Document Quarterly Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure Resident Care Conferences (RCCs) were completed at least quarterly and in conjunction with the required quarterly MDS assessment for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction, and the care plan dated 11/19/25 identified the resident as being at risk for falls due to new admission status, cognitive impairment, and generalized weakness. An RCC and interdisciplinary care plan meeting were documented on 11/19/25, and the quarterly MDS dated 2/3/26 showed severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. However, review of the clinical record from 11/20/25 through 3/8/26 did not show that an RCC was scheduled or held to correspond with the 2/3/26 MDS. The Interdisciplinary Care Plan Meeting Documentation showed the next RCC for this resident occurred on 3/9/26, more than one month after the quarterly MDS. The MDS Coordinator (RN #3) stated that RCCs are to be completed at least quarterly with review of the resident care plan and acknowledged that the resident should have had an RCC scheduled around the time of the 2/3/26 MDS. RN #3 reported an RCC was initially scheduled for 2/19/26 but could not provide documentation that the meeting occurred or that invitations were sent to the resident or representative, noting she had been on vacation when invitations should have been sent. The DON confirmed that all residents are to have quarterly RCCs that correlate with the MDS date and be documented in the clinical record, and that if an RCC is rescheduled, there should be documentation explaining the reason and new date. Review of the Comprehensive Care Planning policy showed requirements for informing residents of their right to participate in care planning, providing advance notice of conferences, documenting when participation is not practicable, and reviewing and updating the care plan at least quarterly with the MDS; no separate RCC policy was provided despite request.
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