Failure to Revise Care Plan After Contraband Incident
Penalty
Summary
The facility failed to revise the care plan and implement appropriate interventions after a resident with a diagnosis of unspecified schizophrenia and moderate cognitive impairment was found with contraband, specifically a metal fork, under his mattress. Staff discovered the fork during a routine room check and removed it, subsequently informing the resident of the unit rules regarding unauthorized items. The incident was documented, and the assigned Program Counselor and other staff were notified. However, although there was discussion among staff about initiating new interventions, such as checking the resident for contraband after meals, these interventions were not added to the resident's care plan. The care plan, which was updated to reflect the incident of inappropriate behavior, did not include any new behavioral interventions to prevent the resident from taking contraband from the dining room. Interviews with staff, including the Program Counselor and the DON, confirmed that no new interventions were added to the care plan following the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition dictate. Additionally, some staff members were unaware of the need to search the resident for contraband after meals, indicating a lack of communication and implementation of appropriate interventions.