Failure to Revise Care Plans and Include Required IDT Members
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and complete person‑centered care plans based on residents’ current conditions and to ensure required Interdisciplinary Team (IDT) participation in care plan meetings. For one resident with a history of hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction, record review showed that the care plan last updated on 12/29/25 did not include any goals or interventions addressing newly developed bilateral hand contractures or the support needed for this condition. During interview, the Unit Manager confirmed that this resident’s care plan did not meet her expectations because it omitted the bilateral hand contractures and related care and support needs. For another resident admitted with chronic idiopathic constipation, a personal history of other digestive system diseases, and cerebral palsy, physician orders dated 01/10/26 included lactulose to be given daily for constipation, but the care plan dated 01/20/26 did not address chronic idiopathic constipation or related care and support. The Unit Manager confirmed this omission during interview. In addition, review of a third resident’s Care Plan Conference form showed that the documented attendees included the resident, the resident’s representative, a nurse, rehab, and the Social Services Director, but did not include the resident’s CNA or physician. In interview, the Social Services Director stated that the IDT meetings included rehab, a nurse, and the director of social services, and that the provider and CNA were not included because she did not know they had to be in attendance.
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.