Failure to Update Care Plan Following Escalation of Resident Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to reflect recent changes in behavior and to provide appropriate direction to staff. The resident, who has Alzheimer's disease with late onset, dementia, and an anxiety disorder, exhibited a significant increase in behavioral issues, including physical and verbal aggression, spitting, yelling, throwing objects, and involvement in altercations with other residents. Despite these documented incidents and changes in the resident's condition, the care plan was not updated to include new interventions or reflect the care being provided, such as the initiation of 1:1 supervision and medication adjustments. Documentation reviewed by the surveyor showed multiple behavioral incidents over several days, with staff and LPNs intervening and reporting the events. However, the care plan remained unchanged from its original version, and new interventions were not formally documented until after the survey process began. The facility's own policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in the case of this resident.