Failure to Revise Care Plan After Readmission Leads to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was readmitted after a transfer to a General Acute Care Hospital (GACH) due to aggressive behavior. Upon readmission, the resident, who had diagnoses including encephalopathy, schizophrenia, and bipolar disorder, did not require 1:1 supervision according to staff, and the behavior care plans were not updated. The Minimum Data Set Coordinator (MDSC) acknowledged that the care plan should have been reviewed and revised upon the resident's return, but this was not done. As a result of the lack of care plan revision, the resident exhibited further behavioral issues, including throwing a book at another resident. Documentation indicated the resident was anxious, irritable, emotionally labile, and demonstrated poor impulse control and unpredictable behavior. The Director of Nursing (DON) confirmed that care plans need to be updated upon readmission to prevent gaps or delays in care, and the facility's policy required comprehensive care planning to be reviewed and revised as needed.