Failure to Timely Review and Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely review and revise care plans for four of nine residents following incidents of resident-to-resident physical abuse. Multiple abuse investigation reports documented physical altercations between residents, such as one resident smacking another's face, swatting another's back, and grabbing a wrist. Although the investigation reports indicated that the involved residents' care plans were reviewed or revised, the actual care plans did not reflect timely updates or new interventions related to the abuse incidents. For example, care plans for residents with histories of dementia, psychiatric diagnoses, and aggressive behaviors were not updated to address the specific abuse events as required. Record review and staff interviews confirmed that the care plans for the involved residents had not been updated as they should have been after each abuse allegation. The facility's own abuse policy requires prompt investigation and necessary changes to prevent future occurrences, but documentation showed that care plans remained unchanged or were not revised in a timely manner following the incidents. The lack of timely care plan review and revision was acknowledged by facility leadership during the survey.