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.
Failure to hold timely IDT care plan reviews after MDS assessments. For multiple residents, IDT meetings were not held within the required timeframe after annual, quarterly, or significant change assessments, and one resident’s care plan was not updated to reflect post-hospital left hip incision care after a fall, hip fracture, and surgery. Staff interviews showed the MDS Coordinator and LSW used scheduling practices that did not align with the assessment-based timing expected for care plan review.
A resident with dementia and behavioral health diagnoses had a care plan that was not accurately revised to reflect current needs. Records showed impulsive behavior, poor decision making, and wandering risk, including attempts to leave the facility and unsafe outdoor activity, but the care plan did not include specific interventions such as boundary setting or other safety approaches.
The facility failed to show that an IDT reviewed and revised a resident’s care plan after an MDS quarterly assessment. The record lacked evidence of an IDT meeting within 7 days of the assessment, and when surveyors asked for documentation, the LSW and DON could not provide meeting notes or other proof that the meeting occurred.
Care plans were not updated for a resident requiring EBP due to open wounds and for another resident with a new Type 2 DM diagnosis. Surveyors found an EBP sign posted outside one resident’s room, but the care plan did not address EBP use. For the other resident, the clinical record showed a new Type 2 DM diagnosis, yet there were no associated notes and the care plan was not revised to include problems, goals, or interventions.
Care plans were not resident centered or accurately updated for 3 sampled residents. A resident with a Foley catheter and pressure wounds, a resident with non-weight bearing status and heel wounds, and a resident with buttock and thigh wounds all had care plans that failed to address EBP; one resident’s plan also omitted the pressure wounds and weight-bearing status. The DON confirmed the missing care plan elements.
A resident’s record showed an MDS admission assessment, but there was no evidence that an IDT meeting was held within 7 days afterward to review and revise the care plan. During an interview, the DON and an RN reviewed the EMR and confirmed that the required IDT meeting had not been held following the assessment.
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