Failure to Include Required Interdisciplinary Team Members in Care Plan Preparation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were prepared by a complete interdisciplinary team (IDT) for two of three residents reviewed. For one resident with severe cognitive impairment, the care plan meeting was attended only by the social worker, MDS coordinator, and rehab director, with no documented evidence that the resident, their representative, or other required IDT members participated or were invited. The resident's representative confirmed not being given the opportunity to attend or participate in the care plan preparation. For another resident who was cognitively intact, the care plan meeting included only the social worker, MDS coordinator, and the resident's representative, with no documentation that the resident or other required IDT members were involved or invited. The resident stated she was not given the opportunity to participate in her care plan preparation. Multiple staff interviews confirmed that attending physicians and other designated providers did not participate in the preparation of individual comprehensive care plans, and there was no documentation to show their involvement.