Failure to Review and Update Care Plans with Resident Participation After MDS Assessments
Penalty
Summary
The facility's Interdisciplinary Team (IDT) failed to review and update care plans following annual and quarterly Minimum Data Set (MDS) assessments and did not involve residents or their representatives in the care planning process for two sampled residents. For one resident with diabetes mellitus type 2 and congestive heart failure, records showed no evidence of IDT review or resident/family participation in care plan meetings after the most recent quarterly MDS. The resident confirmed not being invited to any care plan meetings, and staff interviews revealed a lack of awareness and implementation of required care plan reviews and meetings for long-term residents. Similarly, another resident with poly-osteoarthritis, dementia, and hypothyroidism had not participated in a care plan meeting since an initial conference, despite being cognitively intact and dependent on staff for daily activities. Documentation did not show IDT review or resident/family involvement in care plan updates after the most recent comprehensive annual MDS. Staff interviews confirmed that only initial care plan meetings were being conducted for new admissions, and ongoing care plan reviews and meetings for long-term residents were not held as required.