Care Plan Lacked Documentation of Behavioral Triggers
Penalty
Summary
The facility failed to ensure that care plans were revised according to residents' needs, as evidenced by the case of one resident with dementia and major depressive disorder. The resident's care plan, last revised on 11/14/24, instructed staff to investigate and identify potential triggers for aggressive behaviors and to use non-pharmacological interventions, as well as to keep the resident within line of sight due to aggressive tendencies. However, the care plan did not document specific triggers that led to the resident's aggression toward others. During an interview, the DON confirmed that the resident becomes agitated by overstimulation from loud sounds or excessive activity, and that the care plan did not include this information, leaving staff without guidance on identifying triggers for the resident's aggressive behaviors.