A resident’s care plan was not revised to match current transfer needs. The resident and a staff member stated the resident only needed contact guard assist with 1 staff member standing by, but the Kardex and care plan still listed transfers as totally dependent with 2 staff assists. Therapy notes also showed the resident was a contact guard assist for all transfers, and the care plan had not been updated to reflect this.
A resident with COPD was observed using oxygen at settings above the ordered range, and the resident stated he or she often changed the LPM setting independently. An LPN confirmed the resident frequently adjusted the oxygen, but the respiratory care plan only listed the ordered range and did not note the resident’s self-adjustment or the need for staff monitoring.
Care Plans Not Updated for Code Status, Insulin, UTI/Sepsis, and Constipation: The facility failed to keep care plans current for two residents. One resident’s care plan remained Full Code despite DNR orders, did not address ordered insulin regimens, and still reflected UTI/sepsis-related needs without evidence of ongoing interventions. Another resident’s care plan was not revised after two hospitalizations for constipation treatment. The DON confirmed the care plans were not updated to reflect these current conditions and treatments.
IDT care plan reviews were not completed within the required timeframe after MDS assessments for multiple residents. Record review showed that several residents had annual, quarterly, or significant change MDS assessments, but the documented IDT meetings were either held more than 7 days after the assessment or, in one case, only before the assessment. The MDS Coordinator confirmed the meetings were not held within 7 days after MDS completion and stated the facility schedules IDT meetings 14 days from the ARD and only on Wednesdays.
The facility failed to have the IDT review and revise care plans after each MDS assessment for multiple residents. Surveyors found that some IDT meetings occurred before the MDS was completed, while others had no evidence of an IDT meeting within 7 days of the assessment. The DSSD stated the facility believed it had 14 days and used the ARD rather than the MDS completion date.
Failure to hold IDT meetings within the required timeframe after MDS assessments. Record reviews showed multiple residents had quarterly, annual, or Significant Change MDS assessments without evidence of an IDT meeting within 7 days, and several meetings were held 11 to 19 days after the assessment. The DOSS confirmed the facility was scheduling care plan reviews after the MDS process and was using a 2-week timeframe instead of the required 7 days.
The facility failed to ensure IDT review and revision of care plans after MDS assessments for multiple residents. Records showed that for several residents, no IDT meeting was documented within the required 7-day window after quarterly, annual, admission, or significant change MDSs, and in some cases the IDT meeting occurred before the MDS was completed or outside the required timeframe. Staff interviews confirmed that some IDT meetings were completed before the MDSs and others were not completed on time.
Failure to Hold IDT Care Plan Meetings Within Required Timeframe: The facility failed to document IDT care plan meetings within 7 days of quarterly MDS assessments for 5 residents. Record review showed multiple quarterly MDSs with no evidence of timely IDT meetings, and staff interviews confirmed the missing documentation; the MDS Coordinator could not provide evidence that family or representatives requested meetings outside the required timeframe.
Failure to Hold Required IDT Care Plan Meetings The facility failed to review and revise care plans by an IDT, including resident and/or representative participation to the extent possible, after required MDS assessments for three residents. Records lacked evidence that IDT meetings were held within 7 days of quarterly, annual, and admission MDS completion, and both the Regional Director of Operations and the social worker confirmed the meetings were not done within the required timeframe. One resident also stated he/she had not met with the care team and had concerns to discuss.
A resident with Alzheimer’s disease, depression, DM2, a left foot ulcer, toe amputations, and PAD had a care plan that was not updated to match current wound care orders, including changes from a PICO dressing to other wound dressings and the fact that the wound vac was no longer in use. The care plan also was not revised after new psychotropic meds, Seroquel and Trazodone, were ordered, and it did not reflect the resident’s specific dementia-related activity preferences or interventions for mood and behaviors. The DON confirmed the care plan had not been revised to reflect the resident’s current needs.
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