Failure to Update Care Plan with 1:1 Monitor After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to update the care plan for a resident with a history of aggressive behavior following an incident in which the resident struck another resident. Despite the provider's recommendation and the Interdisciplinary Team's (IDT) decision to implement a 1:1 monitor after the incident, this intervention was not added to the resident's care plan. The care plan continued to list previous interventions such as allowing the resident to express concerns, approaching calmly, and consulting psychiatry as needed, but did not reflect the new 1:1 monitoring requirement. Record reviews and staff interviews confirmed that the 1:1 monitor was being implemented in practice, as a CNA was assigned to monitor the resident, but this intervention was not documented in the care plan as required by facility policy. The Director of Nursing acknowledged that the care plan should have been updated during the IDT meeting and confirmed that the omission was not in line with facility expectations or policy, which requires care plan revisions upon a change in resident status.