Failure to Update Care Plans Following Abuse and Behavioral Incidents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised in response to significant events for three residents reviewed. Specifically, one resident reported being beaten by staff, but their abuse care plan was not updated to reflect this allegation. Another resident was exposed to inappropriate behavior by a peer, yet neither the abuse care plan for the affected resident nor the behavior care plan for the resident exhibiting the behavior was updated to document the incident. These omissions occurred despite facility policy requiring care plans to be revised as residents' conditions or circumstances change. Record reviews showed that the residents involved had complex medical and psychiatric histories, including diagnoses such as COPD, schizophrenia, dementia, and major depressive disorder. The care plans in place prior to the incidents included interventions for abuse risk and behavioral concerns, but these were not revised to address the new allegations or behaviors. Interviews with nursing staff and administration confirmed that care plans should have been updated following these events, but this did not occur.