Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCPs) for two residents following an altercation between them. An incident report documented that one resident, with severe cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, stuck their tongue out at another resident, who then physically grabbed the first resident. Staff immediately separated the residents. However, a review of both residents' progress notes and CCPs revealed no documentation of behaviors or new interventions related to the incident. The CCPs for both residents had not been updated around the time of the altercation, despite one resident having a history of verbal aggression and both having cognitive impairments. During an interview, the DON confirmed that there was no behavior documentation, care plan update, physician notification, or family notification regarding the incident, although these actions should have occurred. Facility policies require that care plans be reviewed and revised as necessary, with updates for new or modified interventions, and that behavioral health services be individualized and person-centered. The lack of documentation and care plan revision following the incident constituted a failure to meet these standards.