Failure to Document Interdisciplinary Care Plan Meetings and Resident Participation
Penalty
Summary
The facility failed to ensure that care plans were prepared, reviewed, and revised by an interdisciplinary team (IDT) with the participation of residents and their representatives, as required. For one resident with Alzheimer's disease and dementia, the clinical record did not contain documentation supporting the behavioral care plan's claims of inappropriate behaviors, nor was there evidence of an IDT meeting prior to the initiation of the care plan. Interviews with staff confirmed the absence of documentation for both the alleged behaviors and the required IDT meeting. Additionally, two other residents did not have documented care plan meetings within the required quarterly timeframe. One resident was unsure when their last care plan meeting occurred, and the record confirmed the last meeting was several months prior, with no documentation of a more recent meeting. Another resident's family member reported not having attended a care plan meeting recently, and the record also lacked documentation of a recent meeting. Facility policy requires quarterly care plan meetings for all residents, but this was not consistently documented or followed.