Failure to Revise Care Plans and Conduct Quarterly Interdisciplinary Reviews for Discharging Residents
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans and to conduct required interdisciplinary care plan reviews for multiple residents. For one resident with multiple chronic conditions including muscle wasting/atrophy, diabetes, peripheral vascular disease, congestive heart failure, atrial fibrillation, anemia, major depressive disorder, hypertension, and prior cerebral infarction, the care plan last revised in April documented that the resident wished to remain in the facility long term, with goals stating the resident would remain LTC and interventions directing the social worker and care navigation to meet quarterly and as needed regarding the resident’s wishes to remain LTC. The resident was later discharged to a group home, but the care plan was never updated to reflect problems, goals, or interventions related to discharge to the community, despite this change in status. The same resident’s record showed that the last documented interdisciplinary care plan meeting occurred in January, while quarterly MDS assessments were completed in April and July. There was no documentation of care plan review meetings at the time of those quarterly MDS assessments. During interviews, the social worker, who was responsible for updating care plans for discharge status and scheduling care plan meetings, and the assistant administrator confirmed there were no care plan review meetings for this resident after January, and the social worker could not explain why quarterly meetings were not held. The ADON stated that care plan review meetings were supposed to be conducted quarterly around the time of required MDS assessments and that discharge plans were expected to be revised when discharge status changed, but this did not occur for the resident. For a second resident with diagnoses including NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive chronic kidney disease with stage 5 CKD or ESRD, the care plan contained an active focus area stating the resident wished to remain LTC at the facility up to the time of discharge. The discharge summary from the medical provider documented the resident was stable for discharge to a group home with home health PT and OT. However, the clinical record contained no documented evidence that the care plan was reviewed or revised to include discharge planning or the discharge location, and there was no documentation of planning for medication administration or education, dialysis access site management, medical equipment needs, or arrangement of home health services as referenced in the provider documentation. Social work notes only reflected that the resident was interested in discharging to a group home and that the discharge date was postponed, and the unit manager could not recall any care plan meeting to discuss discharge planning for this resident.
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.