F0553

E

Failure to Conduct IDT Care Plan Conferences With Resident Participation

Santa Monica, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement its policy and procedure for conducting care plan conferences and involving residents and/or their representatives in the development of person-centered plans of care. For Resident 1, who was admitted with atrial fibrillation, peripheral vascular disease, and an anxiety disorder, the Minimum Data Set (MDS) showed intact cognitive skills for daily decision-making and a need for moderate assistance with ADLs. However, review of the medical record as of 1/23/2026 showed no documentation of an Interdisciplinary Team (IDT) meeting or care plan conference upon admission. Resident 1’s care coordinator reported visiting the facility to inquire about the resident’s plan of care and goals, but no staff could provide a care plan or related documentation, and attempts to obtain information from social services were unsuccessful.

For Resident 3, admitted with chronic respiratory failure, acute kidney failure, and muscle weakness, the MDS indicated intact cognitive skills for daily decisions and total dependence on staff for ADLs. A review of this resident’s medical record as of 1/23/2026 similarly revealed no IDT meeting or care plan conference upon admission. During an interview and record review, the MDS nurse confirmed that there was no IDT care conference completed and no discussion documented regarding Resident 3’s plan of care.

For Resident 4, admitted with benign prostatic hyperplasia, atrial fibrillation, and muscle weakness, the MDS showed intact cognitive skills for daily decisions and a need for maximal to total assistance with ADLs. As with the other residents, review of the medical record as of 1/23/2026 showed no IDT meeting or care plan conference upon admission. The MDS nurse confirmed that no IDT care conference or discussion of the plan of care had been completed for this resident. The DON and interim Social Services Director both stated that, per facility practice and policy, an IDT care conference including the resident and/or resident representative should be held upon admission to discuss the plan of care, services, and discharge planning. The facility’s written policy, “Care Plan Conference,” requires the IDT, in conjunction with the resident or representative, to develop the plan of care based on the comprehensive assessment and to hold care plan conferences within specified timeframes, encouraging resident and representative participation, which did not occur for these residents.