Failure to Develop Comprehensive Care Plans with Full Interdisciplinary Team Participation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed within 7 days of the comprehensive assessment and that these care plans were prepared, reviewed, and revised by the full interdisciplinary team (IDT) as required. For one resident, the care plan conference summary indicated that only the Activities Director, Unit Manager (LPN), Dietician, and Social Work Director participated in updating the care plan, with no documentation of participation or input from the attending physician, a registered nurse, or a nurse aide responsible for the resident. Additionally, there was no evidence that these missing team members communicated their updates to the care plan. For another resident, the comprehensive care plan was not completed within the required 7-day timeframe following the comprehensive assessment. The care plan conference summary lacked documentation of participation from the resident or their representative, and the only signatures present were from the Director of Social Work, Director of Activities, and Dietician. Attempts to contact the resident's family for participation were unsuccessful, and there was no documentation of involvement from the attending physician, registered nurse, or nurse aide. Staff interviews confirmed the absence of documentation supporting full IDT participation in the care plan development.