Failure to Update Care Plan After Staff-to-Resident Verbal Incident
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for a resident after an incident in which a certified nursing assistant (CNA) raised her voice and used inappropriate language while providing care. The incident was reported by the resident's roommate, who overheard the CNA loudly using profane language during care. Despite this report, the resident's care plan was not updated to address the incident or to ensure that the resident's needs were being met in light of the event. The resident involved had significant medical and cognitive impairments, including senile degeneration of the brain, epilepsy, and unspecified psychosis, and was dependent on staff for most self-care needs. The resident was also on hospice care and had a BIMS score indicating severe cognitive impairment. Observations and interviews confirmed that the resident was unable to communicate effectively and relied on staff for emotional, intellectual, physical, and social needs. The care plan in place prior to the incident included general interventions for staff interaction but was not revised following the reported event. Interviews with staff and review of records revealed that although the incident was reported to facility leadership and investigated, there was no documentation of a care plan update or new interventions to address the resident's psychosocial or emotional needs after the incident. The facility's policy required ongoing review and revision of care plans to reflect changes in residents' needs and preferences, but this was not followed in this case.