Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with severe cognitive impairments, resulting in an altercation during an unsupervised smoke break. One resident, diagnosed with aphasia following cerebral infarction and assessed with a BIMS score of 0/15, threw an ashtray at another resident after being called a racial slur. The care plan for this resident had been updated for previous behavioral incidents, including emotional outbursts and altercations, and included interventions such as psychiatric evaluation and 1:1 supervision for limited periods. However, there were no interventions specifically addressing increased supervision or monitoring between these two residents, despite their history of conflict. The second resident involved, diagnosed with epilepsy and cerebral palsy and assessed with severe to moderate cognitive impairment, had a care plan updated for verbally abusive behavior and a prior altercation. Interventions included encouraging respectful behavior, 15-minute checks, and 1:1 supervision, but did not include measures to monitor interactions with the other resident involved in the incident. Staff interviews confirmed that no staff were present during the smoke break when the altercation occurred, and that the care plans lacked targeted interventions to prevent further incidents between these two residents.