Failure to Develop Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan addressing behavioral issues for one resident with a history of epilepsy and encephalopathy. Despite multiple documented incidents of the resident exhibiting behaviors such as yelling, screaming, using foul language, and threatening staff, no care plan was created to guide staff in managing these behaviors. Progress notes and behavior monitoring records indicated repeated episodes of agitation, anxiety, and disruptive conduct, some of which interfered with care and created a disruptive environment. Interventions were inconsistently applied, with some instances where redirection was attempted but ineffective, and other instances where no interventions were implemented or documented. Staff interviews confirmed the ongoing nature of the resident's behaviors and the absence of a care plan or consistent interventions to address them. Nurse aides and licensed nurses acknowledged that the resident frequently displayed challenging behaviors and that staff often had to wait for the resident to calm down before care could be provided. The lack of a comprehensive care plan and clear interventions for managing the resident's behaviors constituted a failure to meet regulatory requirements for individualized resident care.