Failure to Conduct Required Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure quarterly care plan meetings were held for a sampled resident, as required following the comprehensive assessment. The resident was admitted on 07/03/25 and had a BIMS score of 13, indicating intact cognitive functioning. Record review showed that a comprehensive care plan meeting occurred on 07/11/25, but no additional care plan meeting notes were found in the resident’s EHR thereafter. During interview, the resident stated they did not recall attending any care plan meetings. The MDS Coordinator, who was responsible for conducting care plan meetings for LTC residents, stated they were not aware that quarterly care plan meetings were required with residents or their representatives and confirmed that the only care plan meeting documented for this resident occurred in July 2025. The DON reported that the facility did not have a policy and procedure for care planning and instead just followed CMS guidelines, and it was further identified that the MDS Coordinator was supervised by a corporate nurse consultant who had been involved in training and tracking care-plan meetings.
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