Failure to Develop and Implement Comprehensive Care Plan for Resident with Unsafe Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's behaviors that posed safety risks to themselves and others. Documentation showed that the resident repeatedly obtained and concealed potentially dangerous items such as scissors and a stapler, sometimes refusing to relinquish them when approached by staff. The resident also exhibited behaviors such as taking items from the medication cart, hiding them in their room, and threatening staff when attempts were made to retrieve these items. Additionally, the resident was observed attempting to access staff offices and locked cabinets, and had a documented history of being physically threatening to both residents and staff. Despite these incidents, a review of the resident's care plan revealed no documented focus, goals, or interventions addressing the resident's unsafe behaviors or the risk of physical threats. Staff interviews confirmed awareness of the resident's actions and history, yet no specific care plan strategies were in place to mitigate these risks. Observations further revealed that potentially dangerous items, such as scissors, were left unsecured on the medication cart, accessible to residents. The Director of Nursing confirmed the absence of appropriate care plan interventions for the resident's behaviors.