Failure to Update Care Plan for Resident Behavioral Changes
Penalty
Summary
Facility staff failed to update the comprehensive care plan for a resident with documented behavioral issues, despite multiple incidents of physical and verbal aggression towards other residents. The resident, assessed as having moderate cognitive impairment, exhibited behaviors such as shoving, making threats, and physically assaulting peers, as recorded in nurse's notes over several months. However, the care plan did not reflect these behaviors or include interventions to guide staff response, contrary to the facility's policy requiring care plans to be revised with changes in a resident's condition. Interviews with facility staff, including a CNA, RN, MDS Coordinator, DON, and the administrator, confirmed that behavioral issues should be documented in the care plan and that interventions should be included. The MDS Coordinator acknowledged responsibility for updating care plans and was unsure why the resident's behaviors were not included. The DON and administrator also stated that such behaviors and interventions should have been care planned, but could not provide a specific reason for the omission, suggesting it may not have been reported to the MDS Coordinator.