Failure to Review Care Plans Timely
Penalty
Summary
The facility failed to review the care plans within seven days after the completion of the comprehensive assessment for three of six sampled residents. Resident 1, who was admitted with diagnoses including spinal stenosis, heart failure, and diabetes, had their Quarterly Minimum Data Set (MDS) assessment completed on November 3, 2024, but there was no documentation of an interdisciplinary care plan meeting. Similarly, Resident 5, with heart failure and diabetes, and Resident 6, with hemiplegia and hemiparesis, both had their Quarterly MDS assessments completed on November 20, 2024, without documented interdisciplinary care plan meetings. The Administrator confirmed the lack of documentation for these meetings during an interview on December 20, 2024.
Plan Of Correction
1. Interdisciplinary care plan meetings have been scheduled for Residents #1, 5 and 6 to review their individual care plans. 2. After completion of the resident's comprehensive and quarterly MDS, residents are to receive notification of their scheduled interdisciplinary care plan meeting to review their individual care plan. An audit of the last 2 weeks will be conducted to determine if residents/responsible parties received notification of the resident's interdisciplinary care plan meeting. 3. The interdisciplinary team will be re-educated on the center's Person Centered Care Plan Policy. 4. A weekly audit of 8 random residents for 4 weeks and then biweekly for 2 months will be conducted to verify that residents and/or responsible parties are receiving notification of the resident's scheduled interdisciplinary care plan meeting. Results of the audits will be presented to the center's QAPI Committee for review and follow up actions as recommended.