Failure to Update Care Plans for Behavioral and Trauma Needs
Penalty
Summary
The facility failed to update and individualize care plans for two residents regarding their behavioral issues and trauma history. For one resident, electronic health records documented an incident where the resident exhibited verbal outbursts and aggressive language towards another resident and staff, but the care plan, last reviewed over two months prior, did not address these behaviors with any problem statements, goals, or interventions. For the second resident, who had a diagnosis of PTSD, the care plan did not include any problems, goals, or nonpharmacological interventions related to PTSD, despite this being a known diagnosis. Interviews with staff confirmed that behavioral interventions and trauma-informed care were being provided to these residents on a daily basis, but these actions were not reflected in the residents' care plans. The lack of documentation and care plan updates meant that the individualized needs and preferences of these residents were not formally recognized or communicated in their care plans, despite ongoing behavioral incidents and known trauma histories.