Failure to Review, Revise, and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment and failed to hold required quarterly care plan meetings with resident participation. For a resident with paranoid personality disorder, major depressive disorder, and COPD, an abuse care plan initiated in December 2023 and last revised in February 2024 showed no further documented evaluation or revision despite subsequent quarterly MDS assessments, contrary to facility policy requiring quarterly and periodic review. Social services staff acknowledged that the abuse care plan should have been updated quarterly and that their department was responsible for this task, noting that a consultant who normally audits care plans had been covering for another social worker. Another resident with seizure disorder, hypothyroidism, and malignant neoplasm of the brain experienced weakness and poor oral intake, leading to a physician order for IV hydration with 0.45% sodium chloride administered over several days; however, there was no documented evidence that the resident’s comprehensive care plan was reviewed and revised to address the IV fluid therapy. In addition, a cognitively intact resident with diabetes mellitus and end stage renal disease, whose MDS documented resident and family participation in assessment and goal setting, did not have a quarterly care plan meeting held as scheduled. Although the care plan meeting schedule showed two planned conference dates, there was no documentation in the medical record that the meeting occurred, and the resident reported not remembering being invited or attending. Staff interviews revealed confusion and differing understandings among the MDS department, social workers, and the DON regarding responsibility for scheduling and conducting these care plan meetings.
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