Failure to Update Care Plan After Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to revise and implement a comprehensive care plan with measurable interventions and timetables following an allegation of staff-to-resident verbal abuse. The resident involved had diagnoses including anxiety, depression, a rib fracture, and hypertension, and was assessed as having intact cognition but required moderate assistance with activities of daily living. The resident reported that a nurse aide made disrespectful and rude comments during care, which was subsequently reported to another staff member and documented by nursing and social work staff. The facility conducted an investigation, but the care plan for the resident was not updated to reflect the incident or to include new interventions addressing the negative interaction. Review of the clinical record and interviews confirmed that, despite the incident and subsequent investigation, there was no documentation of care plan revisions or implementation of specific interventions to address the resident's experience of verbal abuse. The Director of Nursing acknowledged that a comprehensive care plan should have been developed in response to the allegation, but was unable to provide evidence that this had occurred. Facility policy requires ongoing assessment and care plan updates as resident conditions and information change, but this process was not followed in this case.