Failure to Hold and Document Required Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to hold and document required interdisciplinary care plan meetings for three residents following their comprehensive and quarterly MDS assessments. For one resident with a history of traumatic brain injury, anxiety, depression, seizure disorder, and cognitive impairment, the only documented care plan meeting occurred at admission, with no evidence of subsequent meetings despite multiple MDS assessments. Staff interviews confirmed that no further interdisciplinary care plan meetings had taken place, and a note provided as evidence was unrelated to care planning and not part of the medical record. Another resident, who had resided in the facility for several years, had an MDS assessment completed, but there was no documentation of a care plan meeting following this assessment. Staff responsible for scheduling care plan meetings reported leaving messages for the resident's family but did not document these contacts, and acknowledged that no care plan meeting had occurred since the previous year. The lack of documentation persisted through the time of the survey, with no additional evidence provided to show that a meeting had taken place. A third resident, who had been in the facility since the beginning of the year, also had an MDS assessment completed, but there was no indication that a care plan meeting was held afterward. The resident was unaware of any care plan meetings, and staff interviews confirmed that while meetings were supposed to be scheduled based on MDS schedules, there was no documentation to support that a meeting had occurred. These findings demonstrate that the facility did not consistently conduct or document care plan meetings as required for residents following their MDS assessments.