Deficient Care Plan Development, IDT Participation, and Timely Revisions
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted with the required interdisciplinary team (IDT) members for several residents. In multiple instances, care plan meetings were held with only select staff present, such as the Social Services Director, RN, or Activity Director, while other required contributors like the MDS Coordinator, Nurse Aide, Food Service Staff, and Physician were marked as not applicable or did not participate. Interviews with staff confirmed that providers and CNAs typically do not attend or provide input for care plan meetings, and that input from all required disciplines was not routinely sought. Additionally, the facility did not consistently hold care plan meetings within the required 7-day timeframe following the completion of the Minimum Data Set (MDS) assessments. For some residents, there was no documentation of a care plan meeting occurring within seven days after the MDS was completed, and in one case, the care plan meeting was held before the MDS assessment was finalized. Staff interviews confirmed these timing discrepancies and the lack of adherence to required scheduling protocols. The care plans were also not revised to reflect the most current resident information and physician orders. For example, one resident had a new order for daily application of lotion to the extremities, but this intervention was not added to the care plan. Another resident with a history of diarrhea and multiple related physician orders did not have these diagnoses or interventions reflected in the care plan. The DON confirmed that these updates should have been made to ensure the care plans were accurate and current.