F0657

E

Failure to Complete Timely IDT Care Conferences and Update Care Plans With Current Orders and Preferences

Alamogordo, New Mexico Survey Completed on 11-21-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete timely IDT care plan meetings within 7 days of the completion of admission MDS assessments and to revise care plans to reflect current orders, conditions, and preferences for multiple residents. For one resident with COPD, the admission MDS was completed on 09/04/25, but the IDT care conference was not held until 10/06/25. Another resident’s admission MDS was completed on 11/13/25, and as of 11/21/25 there was no record of an IDT care plan meeting. A third resident’s admission MDS was completed on 09/19/25, but the IDT care conference did not occur until 10/08/25. The social services worker stated he was unaware of the required timeframe for IDT care conferences and confirmed that these care conferences were not held within 7 days of the MDS completion.

The facility also failed to revise care plans to reflect changes in residents’ conditions and physician orders. One resident, readmitted with a diagnosis including a fall subsequent encounter, sustained a fall on 11/04/25; although an anti-roll back device was implemented for the resident’s wheelchair after the fall, the existing care plan, which already identified the resident as at risk for falls, was not revised to include this new intervention. For the resident with COPD, physician orders dated 09/25/25 specified oxygen at 3 LPM continuously, but the care plan, dated 09/03/25, continued to state oxygen at 2 LPM PRN for hypoxia, and staff did not revise the care plan when the oxygen order changed. The Regional Clinical Nurse confirmed that the care plan did not match the current oxygen order and that staff were expected to revise care plans when orders changed.

Additional failures to update care plans were identified for residents with psychiatric and activity needs. One resident with schizophrenia had multiple physician orders related to antipsychotic medication management, including thioridazine dosing, BMP every three months, mood and behavior monitoring with documentation in progress notes, and ECG every six months, but these interventions were not documented in the resident’s care plan dated 10/14/25. Another resident’s activities initial assessment documented that being around animals, keeping up with the news, participating in groups, going outdoors, and morning and afternoon activities were very important, yet the care plan dated 09/16/25 did not include these personal preferences or specify the frequency of activity participation. The Activities Director confirmed that the resident’s care plan did not reflect the interests and frequency identified in the initial assessment.