Failure to Review and Revise Care Plans After Assessments
Penalty
Summary
Facility staff failed to ensure that resident care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. For one resident, there was no documentation verifying participation in care plan meetings, and the Director of Social Work was unable to provide proof that required meetings were conducted or that invitations were consistently sent. Another resident reported concerns about not having quarterly care plan meetings, and documentation could only be provided for a single meeting within the required timeframe. Additionally, quarterly screenings for rehabilitation services were not consistently performed as expected. For a third resident, after discharge from physical and occupational therapy for contracture management, the recommended nursing interventions were not entered into the electronic medical record, and the care plan was not updated to reflect these recommendations. The Director of Rehabilitation and the occupational therapist were unable to confirm when the last quarterly evaluation was conducted, and orders for nursing to follow the discharge recommendations were never placed. These findings demonstrate a pattern of incomplete care plan reviews, lack of interdisciplinary team involvement, and insufficient documentation following assessments and therapy discharges.