Failure to Revise Care Plans After Abuse Incident and Community Access Changes
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents following significant events related to abuse and community access. For one resident, after an altercation with another resident that resulted in a large bruise on the forehead and a report of being repeatedly punched, the care plan was not updated to address the risk for abuse or to reflect the incident. The Director of Nursing confirmed that the care plan did not include any information about abuse, despite the resident having an intact cognitive status as determined by a BIMS score of 13. Additionally, the same resident's care plan for supervised community access had an expired goal target date and was not updated in a timely manner, as acknowledged by the Social Service Director. For another resident, the care plan included expired goal target dates for both community access and abuse/neglect, with the resident expressing concerns about being on restriction and disputing the medical justification for it. The Social Service Director confirmed that the care plan did not reflect the current need for supervised community access and that the target dates were not current. The facility's policy requires care plans to be reviewed and revised after each assessment and with any significant change, but this was not followed for these residents.