Failure to Update Abuse/Neglect Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update and revise the Abuse/Neglect Care Plan for a resident after a sexual abuse allegation was reported. Interviews with the Social Service Director, MDS Coordinator, and Social Service Coordinator confirmed that the care plan should be updated whenever there is an allegation of abuse, and that the Social Service Department is responsible for these updates. Despite this, the resident's abuse/neglect comprehensive care plan was last updated over a year prior to the reported incident, and was not revised following the new allegation. Record review showed that the resident had multiple risk factors, including diagnoses of aphasia, dementia, bipolar disorder, and a history of cerebrovascular disease. The care plan did note previous allegations of verbal aggression and sexual abuse from a peer, but was not updated to reflect the most recent incident. Facility policy requires that care plans be reviewed and updated quarterly, annually, and with any significant change, including abuse allegations, but this was not followed in this case.