Failure to Conduct Interdisciplinary Quarterly Care Plan Reviews
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised on a quarterly basis with participation from an interdisciplinary team and the resident's representative. The resident in question had diagnoses including dementia, anxiety, and dysphagia, and was identified as severely cognitively impaired, requiring significant assistance with daily activities. Documentation showed that care plan meetings were either not held as required or lacked participation from key interdisciplinary team members such as nursing, dietary, therapy, or recreation. In several instances, only social services and the MDS coordinator attended, and there was no evidence that the resident's representative was consistently invited or present. Further review of the clinical record revealed gaps in the scheduling and documentation of care plan meetings over multiple quarters. Interviews with facility staff confirmed that other departments were not made aware of or invited to the meetings, and the resident's representative reported not being invited or attending recent meetings. The facility's policy required interdisciplinary review and input for care plan development and updates, but this was not followed, resulting in the deficiency.