Failure to Conduct Interdisciplinary Team Meeting After Change in Condition
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) meeting for one of three sampled residents, as required by facility policy. Specifically, a resident with a history of cerebral vascular accident, generalized weakness, and diabetes mellitus was admitted and later readmitted to the facility. The resident was noted to have cognitive impairment and was dependent on staff for activities of daily living. From January 2025 onward, the resident experienced multiple hospitalizations due to gastrostomy tube (g-tube) dislodgements. However, there was no documented evidence that an IDT meeting was conducted to address these incidents, despite the facility's policy requiring such meetings upon admission, quarterly, annually, and as needed, particularly at changes of condition. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that IDT meetings should have been held to involve the resident's representative and develop a comprehensive care plan, especially after repeated g-tube dislodgements and hospitalizations. The facility's policy on comprehensive person-centered care planning also specifies that the IDT team must include the resident and their representative. The lack of documented IDT meetings meant that the resident and their representative were not involved in care planning or decision-making regarding the resident's care needs during these significant events.