F0553

D

Failure to Conduct Readmission IDT Meetings and Involve Resident in Care Planning

Inglewood, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct required readmission Interdisciplinary Team (IDT) meetings and include a resident and her responsible party (RP) in the development and implementation of her person-centered plan of care following hospitalizations. The resident was admitted with diagnoses including cognitive communication deficit, urinary retention, and obstructive and reflux uropathy, and had an indwelling Foley catheter. A History and Physical dated 7/5/2025 documented that the resident could make her own medical decisions, and a Minimum Data Set (MDS) dated 7/9/2025 showed moderate cognitive impairment but indicated she was able to understand and be understood, did not reject care, and that she and her family were active participants in the assessment process.

Record review showed that the resident was admitted with a Foley catheter and later hospitalized in September 2025 and again in December 2025 for complications related to a UTI, after which she was readmitted to the facility. Progress notes for September 2025 contained no indication that a readmission IDT meeting was planned or held. For December 2025, the census tab confirmed a readmission, and progress notes documented that on 12/31/2025 an invitation was sent to the resident and her RP for an IDT meeting; however, this was identified by the Social Services Director as an invitation for a quarterly IDT in January, not a readmission IDT. The progress notes did not show that any readmission IDT meeting occurred in December 2025.

During interviews, the resident and her RP stated that after the December hospitalization, facility staff did not inform them about the plan of care to prevent future hospitalizations and UTIs and that they wanted to be involved in the care planning process. The Social Services Director and an LVN both stated that IDT meetings must occur for every readmission to review the resident’s condition, plan care, and uphold the resident’s right to be informed and involved in care planning. The Director of Nursing and Social Services Director confirmed that facility policies titled “Resident Rights” and “Care Planning – Interdisciplinary Team” required that residents and/or their representatives be part of IDT meetings, that such meetings occur within one week of readmission, and that any inability to participate be documented. They acknowledged that these policies were not followed for the resident’s readmissions, and that the resident’s and RP’s rights to be informed of and participate in care planning were not upheld.