Failure to Revise Care Plan for Resident with Escalating Combative Behaviors
Penalty
Summary
The facility failed to ensure that appropriate interventions, including enhanced monitoring, were implemented for a resident with a documented history of combative behavior towards staff. The resident, who had diagnoses of dementia and a history of traumatic brain injury, exhibited ongoing combative and aggressive behaviors as documented in multiple psychiatric consults and staff reports. Despite these documented behaviors, the care plan did not include specific interventions to address the resident's aggression towards staff, and there was no evidence that the care plan was revised in response to the escalating behaviors. The care plan only addressed wandering and intrusiveness, with interventions such as encouraging diversional activities and walking with staff, but did not address the resident's combative actions. The deficiency was further evidenced when the resident became the aggressor in a physical altercation with another resident, resulting in the need for 1:1 enhanced monitoring only after the incident occurred. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's combative behaviors, and there was no policy provided for care plan revisions based on changes in condition. The facility's policy required the interdisciplinary team to document and adjust interventions based on behavioral changes, but this was not followed in the case of this resident.