Failure to Document and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings with interdisciplinary team (IDT) participation were conducted and documented for five residents following their comprehensive assessments. For each resident reviewed, there was no evidence in the clinical records of care plan meetings being held after the completion of their respective Minimum Data Set (MDS) assessments. Specifically, for one resident with progressive neurological conditions, the 5-day MDS assessment was completed, but there was no documentation of a care plan meeting or IDT review. The Director of Nursing (DON) was unable to provide sign-in sheets or other evidence of these meetings, citing missing documentation and unavailable staff. For other residents, records similarly lacked evidence of care plan meetings with IDT participation after their most recent MDS assessments. In one case, the most current care plan meeting on file predated the latest MDS assessment by several months. The DON acknowledged that documentation was kept on paper in a binder but was unable to produce the required evidence during the survey. The absence of documentation and IDT participation in care plan meetings was consistent across all five residents reviewed.