Failure to Document Rescheduled IDT Meetings in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical record for one resident when an Interdisciplinary Team (IDT) meeting was rescheduled multiple times. The resident was admitted with a cognitive communication deficit but was documented in the History and Physical as able to make medical decisions and, per the MDS, had moderate cognitive impairment, could understand and be understood, and did not reject care. The MDS also showed the resident was dependent on staff for toileting hygiene, bathing, and personal hygiene, had an indwelling catheter, was always incontinent of bowel, and that the resident and family were active participants in the assessment process. The resident stated she wanted herself and her responsible party to be informed and involved in IDT meetings and care planning decisions. Record review of the resident’s progress notes for the relevant month showed no indication that the IDT meeting had been delayed, rescheduled, or cancelled. The Social Services Director later stated that the resident’s IDT meeting had actually been rescheduled three times at the request of the resident and responsible party, but these changes were not documented in the progress notes. The Social Services Director acknowledged that scheduling or rescheduling of IDT meetings should have been documented in the clinical record, including the new date, the reason for the change, and whether the IDT was informed. The DON stated that the resident’s medical record was incomplete because the cancellations and rescheduling of the IDT meeting, and notification of the care team, were not documented.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.