Failure to Revise Care Plans and Hold Proper Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were revised and care plan meetings were held as required for several residents. In one case, a resident who reported an allegation of abuse did not have their behavioral care plan updated following the incident, despite the care plan being last revised prior to the event. Another resident continued to have an active care plan for anticoagulant therapy even after the medication was discontinued, with no update to reflect the change in treatment until it was brought to staff attention during the survey. Additionally, care plan meetings did not consistently include all required interdisciplinary team members. Documentation showed that meetings for one resident were attended by social services, nursing, and the dietician, but not always by the full interdisciplinary team as required. In some instances, the family was notified but did not attend, and there was inconsistency in the presence of therapy staff and other disciplines based on the resident's needs. There was also a lack of documentation confirming that residents were invited to attend their care plan meetings. For one resident, records indicated that only the family had been invited to multiple care plan meetings, with the resident attending just one meeting since admission. There was no evidence in the documentation that the resident had been invited or had declined to attend the other meetings, and the facility could not provide documentation to confirm that invitations were extended to the resident as per their stated process.