Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to ensure that comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team following incidents of resident-to-resident altercations. The care plans were not updated to reflect changes in the residents' status after these incidents, which is a requirement as per the facility's policy. The incidents involved verbal and physical altercations between residents, which were documented in the facility's records but not followed by necessary updates to the care plans. Resident #42, diagnosed with Bipolar Disorder and Anxiety Disorder, was involved in a verbal altercation with Resident #51, who has Peripheral Vascular Disease and PTSD. The altercation was triggered by transphobic text messages sent by Resident #42 to Resident #51. Despite the incident being documented and verified, there was no evidence that the care plans for either resident were reviewed or revised to include new interventions addressing the altercation. Similarly, Resident #50, with severe cognitive impairment, was involved in a physical altercation with Resident #61, who has Alcohol Dependence and other diagnoses. Resident #61 threw water at Resident #50 without apparent cause. Although the incident was documented, the care plans for both residents were not updated to reflect the altercation. Interviews with the Director of Social Services and the Director of Nursing revealed a lack of clarity and responsibility regarding the updating of care plans following such incidents.
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Director of Social Services on 12/09/2024 and 12/10/2024 conducted care plan reviews and revision to assess Resident #42, Resident #50, Resident #51, and Resident #61 for physical, emotional, and behavioral changes post-altercation. DSS updated findings in the medical records and ensured appropriate interventions were implemented. The updated care plans include specific behavioral interventions, safety measures, and triggers identified during the assessment. - The Director of Social Services conducted an urgent IDT huddle on 12/10/2024 to review and revise care plans for all residents involved in the incident. The IDT team was informed of the care plan updates and instructed on implementing the new interventions. Identification of Others Potentially Affected: The facility respectfully submits all residents were reviewed and were not affected by this practice. System Changes to Prevent Recurrence: - The Compliance team on 12/12/2024 reviewed the facility’s care plan policies. No amendments were needed. The Compliance officer re-in-serviced the DSS and social workers to mandate immediate IDT care plan reviews and updates following significant resident incidents, such as altercations, falls, or changes in condition. - The Social Services team and senior nursing team received mandatory training on 12/12/2024 by the compliance officer on Identifying triggers for care plan updates, Proper documentation of incidents and interventions, Collaboration during care plan reviews, and implementing a communication system to ensure direct care staff promptly report significant resident incidents to the IDT for review. - The Compliance team on 12/13/2024 instilled protocol for monitoring and documenting behavior changes following incidents, and responsibilities for ensuring care plan alignment. IDT and all direct care staff as of 12/31/2024 were in-serviced. Quality Assurance Monitoring: - The DSS will perform weekly audits of resident incident reports to verify care plan updates were completed for all significant changes. The DSS will also review a random sample of 10% of care plans weekly for three months to ensure they reflect the resident’s current status and needs. - The audit results will be discussed at monthly Quality Assurance (QA) meetings to adjust training or policies based on findings from the ongoing audits. - The Performance Metrics is set at a compliance target of 100% for care plan updates following significant resident-to-resident incidences. - Audit Tool created. Responsible Party: Director of Social Services