Failure to Implement Comprehensive Care Plan Interventions for Resident with Behavioral Needs
Penalty
Summary
The facility failed to implement comprehensive care plan interventions for a resident with diagnoses including Parkinson's Disease and dementia, who exhibited behaviors such as occasional physical and verbal aggression. The resident's care plan, revised to address these behaviors, included specific interventions such as intervening before agitation escalates, guiding the resident away from distress, engaging calmly in conversation, and, if aggression occurred, staff were to walk away and return later. Despite these documented interventions, staff did not follow the care plan during an incident where the resident became agitated and physically aggressive during incontinence care. During the incident, a CNA held the resident's hands and attempted to reassure her, but the resident pulled away and grabbed another CNA by the hair. In response, the second CNA grabbed the resident's nose and twisted it, causing a nosebleed, and made an inappropriate comment. Interviews with staff and facility leadership confirmed that the care plan was not followed, as staff did not step away and allow the resident time to calm down before reattempting care, contrary to the established interventions for managing the resident's behaviors.