Failure to Update Care Plans After Resident-to-Resident Altercation
Penalty
Summary
Nursing staff failed to develop or update care plans for two residents following a resident-to-resident altercation. Both residents had significant cognitive impairments, as indicated by their low BIMS scores, and complex medical histories including stroke, morbid obesity, anxiety, chronic pain, alcohol abuse, leg fracture, and muscle weakness. The altercation involved one resident attempting to pull another from her bed, but no injury was sustained. Despite this incident, a review of the medical records showed that no care plans were written or updated for either resident after the event. Facility policy requires prompt action to prevent and address resident-to-resident altercations, including reviewing the incident with nursing leadership and making necessary changes to care plans. However, interviews with the Director of Nursing and Social Services Director confirmed that care plans addressing the altercation were missing from the records. Both staff members acknowledged that care plans should have been created or updated for the involved residents, but this was not done.