Failure to Revise Care Plan After Medication Change and Behavioral Incident
Penalty
Summary
The facility failed to revise a resident's care plan following significant changes in the resident's medication regimen and after a facility-reported incident. Specifically, a resident was prescribed an additional dose of Seroquel (Quetiapine Fumarate) by the Medical Director, but the care plan was not updated to reflect this medication change. Progress notes indicated that the resident exhibited agitation and aggression, and although the DON stated that the care plan should have been updated with new goals and interventions, the care plan remained unchanged at the time of review. Additionally, after an altercation between two residents, both diagnosed with dementia, the care plan for the involved resident was not revised to address new behavioral concerns. Documentation and staff statements confirmed that the resident frequently became agitated and wandered into other residents' rooms, yet there was no care plan in place to address these behaviors. The Unit Manager and DON both acknowledged that the care plan should have included interventions for agitation and wandering following the incident, but no such updates were made.