Failure to Initiate IDT Meeting After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) initiated a care conference for a resident following an alleged resident-to-resident altercation. The resident involved had a history of unspecified dementia, generalized anxiety disorder, unspecified psychosis, and hemiplegia/hemiparesis following a cerebral infarction. The Minimum Data Set (MDS) indicated the resident had severely impaired cognitive skills and required supervision or assistance with transfers. After the incident, where the resident allegedly pushed another resident's shoulder multiple times, there was no documented IDT meeting to address the change in condition or to develop a collaborative plan of care. Interviews with facility staff, including the Social Worker, Assistant Administrator, and Director of Nursing, confirmed that no IDT meeting was conducted after the incident, despite facility policy requiring such a meeting following a significant change in a resident's condition. The facility's policy and procedure indicated that the IDT, along with the resident and their representative, should develop and review a comprehensive, person-centered care plan when there is a significant change. The lack of an IDT meeting resulted in a delay in addressing the resident's care needs and implementing necessary interventions.