Failure to Conduct and Update Interdisciplinary Care Plans and Therapy Documentation
Penalty
Summary
The facility failed to conduct required interdisciplinary care plan meetings, update care plans to reflect residents' current needs, and revise care plans following changes in therapy services. For one resident, there was no documentation that care plan meetings were held after each Minimum Data Set (MDS) assessment, nor evidence that the resident or their family representative was included or notified of these meetings. Staff interviews confirmed that attempts to contact family representatives were not documented, and there was a lack of evidence supporting that care plan meetings occurred as required. Additionally, the care plan for this resident was not updated to reflect changes in cognitive status or interventions following an incident involving wandering and inappropriate behavior. Although interventions for elopement and impaired safety awareness were in place, there was no recent review or revision of these interventions, and the last elopement assessment was outdated. The Director of Nursing acknowledged that the care plan interventions were not current and that the resident was no longer at risk for elopement. For another resident, the care plan was not updated after the discontinuation of Physical Therapy (PT) and Occupational Therapy (OT). Despite therapy services being discontinued, nursing staff continued to document that the resident was receiving PT and OT, and the care plan still reflected ongoing therapy. The Director of Nursing confirmed that care plans should have been updated to reflect the discontinuation of services and that staff should not have documented services that were not provided.