Failure to Timely Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised by an interdisciplinary team (IDT), including participation of the resident and/or their representative, within 7 days following each Minimum Data Set (MDS) assessment for multiple residents. Specifically, for several residents, there was either a delay in holding the IDT meeting after the MDS assessment, the meeting was held before the assessment was completed, or there was no evidence that the meeting occurred within the required timeframe. For example, one resident's IDT meeting was held 17 days after the MDS assessment, another's was held 19 days after, and in some cases, the IDT meeting was held prior to the completion of the MDS. Interviews with facility staff confirmed that the scheduling of IDT meetings was based on the Assessment Reference Date (ARD), and not always aligned with the completion of the MDS as required. Additionally, the care plans for some residents were not updated to reflect current diagnoses and care needs. One resident's care plan did not specify the cause or location of chronic pain and failed to address the monitoring and management of atrial fibrillation, a history of genital herpes, and MRSA, despite these being active or relevant diagnoses. The Director of Nursing acknowledged that certain diagnoses had not been included or updated in the care plan, and there was no documentation explaining the omissions.