Failure to Update Care Plan After Resident-to-Resident Incident
Penalty
Summary
The facility failed to update and revise the care plan for a resident following a resident-to-resident incident involving inappropriate physical contact. The affected resident had a history of cerebrovascular accident (stroke), hemiplegia, muscle weakness, and impaired cognition, as indicated by a low BIMS score. The resident required significant assistance with activities of daily living and had documented symptoms of depression. Despite an incident in which another resident entered her room, undid her brief, and touched her inappropriately, the care plan was not updated to reflect this event or to include interventions addressing her psychosocial and mental health needs. Record review showed that the care plan, last revised after the incident, continued to focus on the resident's physical limitations and assistance needs but did not address the trauma or implement behavioral interventions related to the incident. Staff interviews confirmed that the care plan should have been updated to include the incident and related interventions. The facility's policy required care plans to be person-centered, updated as resident needs changed, and to include trauma-informed care, but these requirements were not met in this case.