Failure to Hold and Document Interdisciplinary Care Plan Meetings After Resident Assessments
Penalty
Summary
Facility staff failed to consistently hold and document care plan meetings that included the interdisciplinary team, residents, and their representatives following comprehensive and quarterly assessments, as required. Medical record reviews for five residents revealed missing or insufficient documentation of care plan meetings after multiple Minimum Data Set (MDS) assessments, including annual and quarterly reviews. In several cases, there was no evidence in the electronic medical record or social work documentation that care plan meetings occurred, and when meetings were held, documentation was sometimes limited to handwritten notes not entered into the official record. Staff interviews confirmed the absence of required documentation and, in some instances, the lack of meetings altogether. For example, one resident's records showed no care plan meeting documentation for several assessment periods, and the social work director acknowledged that notes were not entered into the electronic record. Another resident, who had multiple hospital transfers and readmissions, had only two care plan meeting notes documented despite several MDS assessments. Similar patterns were observed for other residents, with gaps between assessments and documented care plan meetings. The DON and social work staff confirmed that care plan meetings should occur after each quarterly MDS assessment, but acknowledged the lack of evidence to support that this was consistently done.