Failure to Develop and Communicate Individualized Behavioral Care Plan After Resident Aggression
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and sufficient staffing to address and manage the behavioral health care needs of a resident diagnosed with schizoaffective disorder-bipolar type and psychotic disorder. After an incident in which the resident choked a CNA, resulting in a temporary involuntary psychiatric commitment, the resident was readmitted to the facility. Upon readmission, the facility did not thoroughly evaluate the resident's behavioral aggressiveness or develop and communicate individualized, comprehensive care plan interventions to all staff, despite the resident's recent history of violent behavior. Documentation and interviews revealed that the interdisciplinary team (IDT) did not discuss or document the resident's aggressive behavior or history of violence in the care plan or IDT notes. Progress notes following the resident's readmission indicated further episodes of verbal and physical aggression, but no individualized behavioral interventions were developed or implemented to prevent further incidents or protect staff and other residents. Staff assigned to supervise the resident were not provided with specific care plans or instructions on managing the resident's behaviors, only general directions to keep the resident safe and prevent fights. This lack of individualized assessment, care planning, and communication led to another serious incident in which the resident, while unsupervised, obtained a bread knife, threatened staff, and acted violently in the facility lobby. The resident's roommate and other cognitively impaired residents were placed at risk during these events. Facility policies required comprehensive, person-centered care plans and thorough behavioral assessments, but these were not followed, as evidenced by the absence of specific interventions and monitoring for the resident's aggressive behaviors.