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.
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.
Surveyors found that care plans for several residents were incomplete or not updated to reflect current physical needs, including fall risk, mobility limitations, and toileting requirements. The plans lacked specific, person-centered interventions and did not accurately address changes in condition following hospitalizations or surgeries, as confirmed by facility staff.
A resident with multiple comorbidities and full assistance needs had a care plan and Kardex that were not updated to reflect the correct size sling for mechanical lift transfers. Although staff used the appropriate blue (extra large) sling as determined by a transfer evaluation, the documentation continued to specify a green (large) sling, and this discrepancy was confirmed by the DON.
The facility did not ensure that care plans were reviewed and revised by the IDT within the required timeframe after each MDS assessment for several residents. In some cases, IDT meetings were delayed, held before the assessment was completed, or lacked evidence of timely review. Additionally, care plans were not updated to address current diagnoses and care needs, such as chronic pain, atrial fibrillation, genital herpes, and MRSA.
A resident with Type 2 Diabetes Mellitus and a history of insulin use had all insulin discontinued by physician order, but the care plan was not updated to reflect this change. The care plan continued to indicate insulin dependence, and there was no documentation that the resident received education or information about the change in diabetes management.
A resident developed a new stage III pressure ulcer on the posterior left foot, but the care plan was not updated to reflect this change or the necessary skin care interventions. Review with the ADON confirmed the care plan did not address the resident's current wound status or treatment needs.
A resident was not invited to or involved in their interdisciplinary team (IDT) care plan meetings, despite documentation of multiple meetings. The resident stated they were unaware of care plan meetings, and the medical record lacked evidence of their participation.
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