Lack of Documented IDT Care Plan Reviews and Conferences After MDS Assessments
Penalty
Summary
Facility staff failed to provide documented evidence that the interdisciplinary team (IDT) reviewed care plans or held care plan conferences with residents and/or their families following each Minimum Data Set (MDS) assessment for two of six sampled residents. For one resident with diagnoses including dysphagia, gastrostomy, gastroesophageal reflux disease, and hemiplegia, quarterly MDS assessments were completed, but there was no documentation of IDT review or care plan conferences after specific assessment dates. The responsible social worker confirmed during an interview that there was no documented evidence of these required reviews or conferences after a certain date. Similarly, another resident with a history of dysphagia, adult failure to thrive, and dementia had quarterly MDS assessments completed, but the last documented IDT care plan review and conference with the resident's family occurred several months prior to the most recent assessments. Staff interviews confirmed the absence of documentation for care plan reviews or conferences after the last recorded date. These findings were based on record reviews and staff interviews, and the deficiency was cross-referenced to F684 Quality of Care.