Failure to Timely Review, Revise, and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to develop, review, and revise comprehensive care plans within the required timeframes and did not ensure the participation of the full interdisciplinary team (IDT) in resident care plan meetings. For multiple residents, care plans were not updated within 7 days of the completion of quarterly Minimum Data Set (MDS) assessments, and required quarterly Resident Care Plan (RCP) meetings were either not held or lacked documentation of attendance. In several cases, only the social worker and the resident attended these meetings, with no participation from nursing, dietary, or other required disciplines, despite facility policy mandating their involvement. Specific deficiencies were observed for several residents. One resident with seizure disorder and chronic obstructive pulmonary disease did not have RCP meetings held after a certain date, and their care plan was not reviewed or revised following MDS assessments. Another resident with epilepsy and depression had no documentation of any RCP meetings during their stay. A resident with hemiplegia and diabetes also lacked RCP meeting attendance records, and their care plan was not updated after multiple MDS assessments. In another case, a resident with chronic pain and opioid dependence experienced a significant change in condition involving outside narcotic prescriptions and the implementation of 1:1 observation, but the care plan was not updated to reflect these changes. Additional findings included a resident with morbid obesity and lymphedema whose care plan focused on discharge planning, but whose RCP meetings were attended only by the social worker and administrator, with no input from nursing or dietary staff. Another resident dependent on hemolytic treatment had RCP meetings attended solely by the social worker, with no participation from other IDT members, despite ongoing issues requiring multidisciplinary input. Interviews with staff confirmed awareness of the requirements but revealed ongoing noncompliance and an inability to explain the lack of IDT participation and timely care plan updates.