Failure to Develop Comprehensive Care Plan After Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing physical abuse for a resident who was punched by another resident. The resident involved had a history of schizophrenia and anxiety disorder, with severely impaired cognitive skills for daily decision-making, and required assistance with several activities of daily living. Despite the incident of physical abuse, the care plan was only updated to address the resulting hematoma and redness on the resident's left eye, but did not include interventions or goals related to the abuse event itself. During a review of the care plan, the Director of Nursing confirmed that there was no updated care plan for physical abuse or resident-to-resident altercation, even though such an incident was documented in the electronic health record. The facility's policy requires the interdisciplinary team to develop individualized, comprehensive care plans for each resident, but this was not followed in this case, resulting in a lack of documented strategies to address and prevent further abuse.