Failure to Update Care Plan After Resident Aggression
Penalty
Summary
The facility failed to update and revise the care plan for a resident following an incident involving aggressive behavior. The resident, who had diagnoses including unspecified dementia, aphasia, and parkinsonism, was involved in a verbal altercation with another resident, during which the resident struck the other individual in the face. Nursing notes documented that the resident was walking in the dining area with only a shirt on, and after being asked to dress appropriately, the altercation occurred. Despite this significant behavioral event, the resident's comprehensive care plan, which had been initiated prior to the incident, was not updated to include new interventions or monitoring for escalating behaviors or potential aggression. Interviews with facility staff, including the DON, confirmed that the care plan should have been reviewed and revised after the incident, and that processes exist for reviewing care plans in cases of escalating behavioral issues. The facility's own policies require the interdisciplinary care team to analyze assessment information, identify risks, and implement targeted interventions, as well as to review and update care plans when there is a significant change in a resident's condition. However, the care plan for this resident did not reflect any changes or new interventions following the aggressive incident.