Failure to Develop and Implement Individualized Care Plan for Resident Behavioral Issue
Penalty
Summary
The facility failed to implement an individualized, person-centered care plan with measurable objectives, timeframes, and interventions for a resident who exhibited problematic behavior. Specifically, after admission, a resident with diagnoses including encephalopathy, traumatic brain injury, and psychoactive substance use, and who was assessed as having severely impaired cognition and requiring moderate assistance with activities of daily living, was found in another resident's room going through personal belongings. This incident was documented in the progress notes. A review of the resident's care plans revealed that there was no care plan addressing the behavior of entering other residents' rooms and taking their belongings. During an interview, the DON confirmed that a care plan for this behavior had not been developed, despite facility policy requiring comprehensive care plans with goals, measurable objectives, and timetables to address identified needs. The lack of a care plan for this behavior was acknowledged as having the potential for repeat incidents and possible resident-to-resident altercations.