Failure to Update Care Plan and Implement Interventions After Repeated Self-Harm Incidents
Penalty
Summary
The facility failed to ensure that interventions were implemented to prevent further potential abuse or self-harm for a resident with a history of psychiatric and behavioral disorders. The resident, who was cognitively intact and had diagnoses including schizoaffective disorder, non-suicidal self-harm, generalized anxiety disorder, borderline personality disorder, and suicidal ideations, experienced multiple incidents of self-harm during their stay. These incidents included self-inflicted lacerations and abrasions to various parts of the body, often requiring medical attention and hospital transfers. Despite repeated episodes of self-harm, documentation revealed that the resident's care plan was not consistently updated after each incident or upon readmission from the hospital. Specifically, there were no care plan updates following several self-harm events, and when updates were made, they did not include preventative measures related to self-harm. The facility's own policy required that care plans be revised if a resident's needs changed as a result of an incident, but this was not followed in practice for this resident. Interviews with facility staff, including a registered nurse, the DON, and the facility administrator, confirmed that care plans were not updated as required. The administrator acknowledged that no interventions were put in place to prevent further harm, citing a reluctance to alter recommendations from the hospital. The facility assessment indicated that the facility was equipped to care for residents with psychiatric and behavioral needs, yet appropriate interventions were not implemented for this resident following multiple incidents of self-harm.