Failure to Conduct and Document Required IDT Care Plan Meetings
Penalty
Summary
The facility failed to ensure that two of four sampled residents had Interdisciplinary Team (IDT) meetings to discuss their plan of care and discharge goals. For one resident, the admission record indicated diagnoses of dementia, bipolar disorder, and Type II Diabetes Mellitus, with mild cognitive impairment and significant assistance required for daily activities. Although an IDT meeting was reportedly conducted with the resident's representative over the phone, the Social Service Director stated that the meeting documentation was not included in the medical record, as it was kept exclusively by her and not entered into the chart. For another resident, admitted with dementia, a fracture, and traumatic subarachnoid hemorrhage, the record review and staff interviews confirmed that no IDT meeting was conducted, despite the resident being able to make her own medical decisions and having intact cognitive skills. The facility's policy requires that IDT meetings be held within 72 hours of admission to address the plan of care, concerns, medications, dietary preferences, and discharge plans. Both the Social Service Director and Director of Nursing acknowledged that the required IDT meetings were not completed or documented as per policy.