Failure to Ensure Timely and Interdisciplinary Care Plan Review and Resident/Representative Participation
Penalty
Summary
The facility failed to ensure that each resident and/or their representative, as well as the full interdisciplinary team (IDT), were invited to and participated in care plan meetings, including both comprehensive and quarterly review assessments. Specifically, for one resident with severe cognitive impairment and multiple complex diagnoses, there was no evidence that quarterly care plan reviews or meetings were held with the appropriate IDT members and the resident or their representative for two out of three required quarters. Additionally, the care plan was not revised within seven days following a quarterly assessment, as required. Record reviews showed that the resident was completely dependent on staff for all activities of daily living and had a BIMS score indicating severe cognitive impairment. Documentation revealed that while some meetings were held, they did not consistently include all required IDT members or the resident’s representative. For example, the only facility staff present at a PASRR meeting was the MDS nurse, and there was no documentation that the resident’s representative was contacted for that meeting. Furthermore, the care plan did not reflect the resident’s current needs as indicated in the most recent MDS assessment, nor did it address the resident’s expressed goal of learning to write her name, despite this being a focus in her habilitation service plans. Interviews with facility staff confirmed that the last documented IDT meeting was several months prior, and that notifications to the resident’s representative about care plan meetings were not documented in the facility’s messaging system. Staff acknowledged that not all required disciplines or the resident’s representative were present at meetings, and that the care plan was not updated in a timely manner following assessments. The facility’s own policy requires interdisciplinary collaboration and timely care plan updates, but these procedures were not followed in this case.