Failure to Develop and Implement Comprehensive Behavior Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address behavioral needs for two residents with significant mental health diagnoses. One resident, admitted with dementia with behavioral disturbances, Parkinson's disease, and major depressive disorder, exhibited multiple documented incidents of aggressive behaviors such as kicking, hitting, pinching, scratching, spitting, biting, and abusive language. Despite repeated documentation of these behaviors by Certified Nurse Aides and nursing staff, there was no behavior care plan in place until after a resident-to-staff incident occurred. Physician orders required behavior notes and interventions to be documented each shift, but the care plan was not initiated on admission, and the abuse care plan was not updated following a subsequent incident. Another resident, admitted with schizoaffective disorder, Alzheimer's disease, and major depressive disorder, also demonstrated verbal and physical aggression, including an incident where the resident attempted to throw a television at another resident. This resident had physician orders for behavior documentation each shift, and multiple behavioral incidents were recorded in nursing notes. However, there was no documented evidence of a behavior or abuse care plan in the electronic medical record. Staff interviews revealed that interventions such as redirection and reapproach were used, but these were not formalized in a care plan, and communication gaps between nursing and Certified Nurse Aides contributed to incomplete documentation and lack of care plan initiation. The facility's policy required comprehensive care plans to be developed by the 21st day of admission and updated with any significant change in condition. However, failures in communication, documentation review, and interdisciplinary coordination led to the absence of required care plans for residents with documented behavioral issues. This resulted in the facility not meeting regulatory requirements to maintain residents' highest practicable physical, mental, and psychosocial well-being.