Failure to Include Residents in Care Planning Meetings
Penalty
Summary
The facility failed to ensure that two residents participated in care plan meetings to discuss their care and discharge goals, as required by federal regulations. For the first resident, documentation showed an admission and readmission with diagnoses including hemiplegia, hemiparesis, and aphasia. The resident had limited decision-making capacity, with the MDS indicating mild cognitive impairment and significant dependence on staff for activities of daily living. Interviews with the Social Service Assistant (SSA) revealed that no Interdisciplinary Team (IDT) meetings were conducted for this resident, and there was no documentation of such meetings. The SSA stated that IDT meetings are important, especially when families are undecided, but none were held for this resident. The family member interviewed was unaware of any IDT meeting being offered and expressed confusion about the care plan and discharge timing. For the second resident, records indicated admission with diagnoses of muscle wasting, spinal stenosis, and radiculopathy. The H&P noted the resident lacked capacity to make decisions, and the MDS showed mild cognitive impairment with dependence on staff for multiple care needs. The SSA did not recall conducting an IDT meeting for this resident and found no documentation of one. The Director of Nursing (DON) confirmed that IDT meetings should occur for each resident, at least quarterly or within 14 days of admission, especially for those with skilled needs. The DON acknowledged that without IDT meetings, care plans would lack cohesion and concerns might not be addressed in a timely manner. A review of facility policies indicated that the Social Service Department is expected to participate in all IDT functions, including care planning and discharge planning meetings. Policies also emphasized the importance of supporting residents' rights and documenting social service interventions in the care plan and progress notes. Despite these policies, the facility did not ensure that the two residents or their representatives were included in the care planning process, nor did it document their participation, resulting in a failure to meet regulatory requirements for resident involvement in care planning.
Plan Of Correction
Affected Residents Resident 1 is no longer a resident of the facility. Resident 2 still resides in the facility. On 5/8/2025, Resident 2 had an Interdisciplinary Team (IDT) meeting. The Resident Representative, Social Services Designee, Dietary Supervisor, Activities Director, MDS RN, and the Physical Therapist attended the IDT meeting. The medications, skin condition, nutrition, activities, rehabilitation, and discharge planning were discussed. The resident representative had no concerns regarding care and services. Other Residents Other residents have the potential to be affected by the same alleged deficient practice. On 5/8/2025, the Social Services Department did a compliance IDT meeting audit on all residents who are under skilled services. All other residents have completed IDT evaluations. No similar findings were noted. Systemic Changes The Director of Nursing and Director of Staff Development gave an in-service on 5/9/2025 to the case manager, social services director, rehab department, dietary supervisor, activities director, and MDS Nurse on the responsibility of the facility in initiating the IDT meetings within seven (7) days upon admission. Discussions regarding care issues or ongoing concerns and discharge planning will be discussed during the IDT meetings. During facility morning stand-up meetings, the team will discuss the IDT Conference Meetings scheduled for that day. Monitoring The Medical Records Designee will monitor compliance by doing a weekly IDT meeting audit on all new admissions to ensure compliance. Findings will be discussed with the Director of Nursing and Social Services Director to be addressed and corrected promptly. Significant findings will be submitted to the Administrator and shall be forwarded to the QA & A Committee quarterly for trending analysis, recommendations, corrective actions, and continuous quality improvement. Completion Date The corrective action will be completed on 5/25/25.