Failure to Develop Care Plan After Resident Altercation
Penalty
Summary
The facility failed to conduct an interdisciplinary team (IDT) conference and develop a care plan for a resident following a resident-to-resident altercation. The resident involved had a history of dementia, restlessness, agitation, Alzheimer's disease, and other mental and behavioral disorders, and was noted to have moderate cognitive impairments. After the altercation, which resulted in the resident being transferred to the hospital, there was no documentation that the IDT addressed the incident or created a care plan to manage the resident's behavior, specifically the behavior of kicking others that was alleged to have initiated the altercation. Facility policy required the IDT to review and update care plans when a change of condition occurred, such as a resident-to-resident altercation. Additionally, policies on safety, supervision, and resident-to-resident altercations required staff to analyze incidents, identify risks, and make necessary changes to care plans. Despite these requirements, the IDT conference notes did not reflect any discussion or intervention planning related to the altercation, and there was no care plan in place to address the resident's aggressive behavior.