Failure to Update Resident Care Plan for Behavioral Issues
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, as required by regulations. The resident, identified as Resident R4, was admitted with diagnoses including high blood pressure, Bipolar Disorder, and dementia. Despite exhibiting significant behavioral issues, such as exit-seeking behavior and inappropriate language, the care plan was not updated to address these needs until much later. Resident R4 displayed a series of concerning behaviors over several months, including requesting sexual favors from another resident, masturbating in the presence of a female resident, and being verbally abusive and physically aggressive towards staff and other residents. These incidents were documented in progress notes, yet the care plan did not include specific goals and interventions to manage these behaviors until January 12, 2025. The Nursing Home Administrator confirmed that the facility did not ensure the resident's care plan was updated and revised in a timely manner. This oversight was identified during a review of facility documents, clinical records, and staff interviews, highlighting a failure to comply with the requirement for comprehensive care planning and revision after each assessment.
Plan Of Correction
Resident # 4 Care plan was updated to reflect hospice services. Resident # 4 Care plan was updated to reflect behaviors. To identify other residents that have the potential to be affected, the MDS/designee completed an audit of current residents to ensure care plans are updated/revised to reflect current status regarding behaviors and hospice services. To prevent this from recurring, the RDCS/designee educated MDS/nursing leadership on requirements of F657 and ensuring that care plans are updated/revised to reflect the resident's specific care needs. To monitor and maintain ongoing compliance, the MDS/designee will audit 5 residents weekly x4 then monthly x 2 to ensure care plans are updated/revised to reflect current status for behaviors and hospice service. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.