Failure to Hold Timely Interdisciplinary Care Plan Meeting with Resident and Representative
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was prepared and reviewed by an interdisciplinary team with the participation of the resident and her representative for one resident. The resident, who had diagnoses including major depressive disorder, type 2 diabetes, and hypertensive heart disease with heart failure, was admitted to the facility and was cognitively intact, as indicated by a BIMS score of 15. She required assistance with eating, oral hygiene, and was dependent on staff for toileting. The resident was actively involved in her assessment and goal setting. A review of records showed that the last care plan conference for the resident occurred in March, with both the resident and her representative in attendance. Although another care plan meeting was scheduled for June, it was not held because the resident was hospitalized at that time, and the meeting was not rescheduled. There were no further care plan conferences documented for the resident after March, and the resident and her representative were not invited to any subsequent meetings. Interviews with facility staff, including the MDS Coordinator, AD, DOR, and DM, confirmed that the resident missed her quarterly care plan meeting and that the oversight was not corrected. Staff interviews revealed that care plan meetings were typically held weekly, with each resident expected to have a meeting quarterly and as needed. The MDS Coordinator was responsible for scheduling and conducting these meetings, which involved the IDT and addressed all aspects of the resident's care. Staff acknowledged that missing care plan meetings could result in residents and their representatives not being informed or able to address concerns. The facility's policy required the IDT, in conjunction with the resident and their representative, to develop and implement a comprehensive, person-centered care plan, which was not followed in this instance.