Failure to Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise care plan interventions for a resident with Alzheimer's Disease who was not responsible for her own medical and financial decisions. The resident had a history of behavioral issues, including a recent altercation where she grabbed and squeezed another resident's arm after that resident wandered into her room. Despite this incident, there was no documentation showing that the facility updated or revised the resident's care plan interventions in response to the altercation. The existing intervention, which involved placing a stop sign on the resident's door to deter others from entering, was observed to be ineffective, as the resident frequently removed the sign and placed it elsewhere in the unit. Multiple observations confirmed that the stop sign was not consistently in place on the resident's door when she was not in her room, and staff interviews acknowledged the ineffectiveness of this intervention. The facility's care plan policy requires periodic review and revision of care plans, with removal of interventions that are no longer applicable, but there was no evidence that the care plan was updated following the incident or that alternative interventions were implemented to address the resident's behavioral risks.