Failure to Update Care Plan After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to update the care plan for a resident following an incident of physical abuse. The resident, who has a history of dementia and severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status exam, exhibited both verbal and physical behaviors. The care plan included multiple interventions to address these behaviors, such as 1:1 monitoring as needed, medication administration, and strategies to prevent frustration and aggression. However, after the resident entered another resident's room and slapped them, there was no evidence that the care plan was reviewed or updated to reflect this incident. Facility policy requires that after an incident of abuse, the care plan should be updated to address the new circumstances and ensure resident safety. Despite this, the care plan for the resident involved in the incident did not show any review or modification following the event. The Director of Nursing acknowledged during an interview that updating the care plan after such incidents is protocol, but admitted that this step was missed in this case.