Failure to Update Care Plan with Enhanced Monitoring After Aggressive Incident
Penalty
Summary
The facility failed to maintain a complete and comprehensive care plan for a resident with a history of physical aggression, including behaviors such as striking out, hitting, kicking, throwing objects, spitting at staff, and refusing care. On the morning of 5/27/25, staff responded to an incident where the resident was observed hitting a nurse in the dining room. Following the incident, the resident was seen by a Psychiatric APRN, and staff implemented 15-minute checks for the next 48 hours as a monitoring intervention. However, review of the resident's electronic medical record revealed that while the care plan for physical aggression was revised on the same day as the incident, no new interventions were documented, and the enhanced rounding of 15-minute checks was not added to the care plan. Additionally, there was no physician order for the enhanced rounding. Interviews with the DON, social worker, and MDS/care plan nurse confirmed that the care plan update for enhanced rounding was missed, and the intervention was not included in the resident's care plan.