Failure to Develop Care Plan After Resident-to-Resident Altercation Resulting in Head Injury
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan for a resident who sustained a possible head injury after being struck multiple times in the head by another resident during an altercation. The resident, who had diagnoses including dementia, schizophrenia, and psychosis, was known to have severely impaired cognition and used a wheelchair for mobility. Following the incident, the resident exhibited facial contusions and a closed head injury, as confirmed by an emergency department evaluation after being transferred for further assessment. Despite the significant change in the resident's condition and the facility's policy requiring care plan updates in response to new problems or changes in condition, there was no care plan addressing the head injury or the events leading to it. Both the Medical Records Supervisor and the Director of Nursing confirmed that the resident's chart lacked a care plan related to the incident, and the facility's policy emphasized the importance of timely, individualized care planning to address residents' health and safety needs.