Failure to Update Care Plans and Complete Post-Fall Monitoring
Penalty
Summary
Licensed nurses failed to initiate or update care plans following a resident-to-resident abuse incident involving two residents, both of whom had severe cognitive impairment and behavioral issues. One resident, diagnosed with Alzheimer's disease and known for physical aggression, grabbed another resident with hemiplegia and severe cognitive impairment, causing distress. Despite staff witnessing the event and facility leadership acknowledging that care plans should have been created or updated, no such documentation or guidance was provided to staff regarding appropriate interventions after the incident. Additionally, after a resident with metabolic encephalopathy and severe cognitive impairment experienced a fall and was sent to the emergency department, licensed staff did not complete the required 72-hour monitoring upon the resident's return. Facility policy required documentation of the resident's status each shift for at least 72 hours following a change in condition, but 48 hours of monitoring were missing. These lapses in nursing services and documentation did not meet professional standards of quality as required by facility policy.