Failure to Review and Revise Care Plans by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team (IDT) for four residents following comprehensive, significant change, and quarterly assessments. According to the facility's policy, the IDT is required to review and update care plans after significant changes in a resident's condition, when desired outcomes are not met, upon readmission from a hospital, and at least quarterly in conjunction with the Minimum Data Set (MDS) assessment. However, record reviews for multiple residents revealed that these care plan meetings and updates did not occur as required. One resident with epilepsy, who was cognitively intact, had no documentation of IDT care plan meetings after each MDS assessment. Another resident with a stage four pressure ulcer, also cognitively intact, had no evidence of an IDT care plan meeting after the MDS assessment, and reported not participating in any care plan meetings. A third resident with Alzheimer's disease, dementia, depression, and an activated healthcare proxy had no record of IDT care plan meetings after MDS assessments, and the healthcare proxy confirmed never being invited to participate. The social worker responsible for coordinating these meetings admitted to not conducting them due to inconsistent work attendance over several months, and the DON acknowledged that care plan meetings had not been happening due to staffing challenges. Additionally, a resident with Alzheimer's disease and severe cognitive deficit had significant changes in condition documented in MDS and activity of daily living flow sheets, such as being always incontinent and dependent for mobility and self-care. Despite these changes, the resident's care plans were not updated or reviewed to reflect the current status. The DON confirmed that care plans were not revised as required following significant changes, again citing staffing issues as the reason for the lapse.