Failure to Update Care Plans After Resident Altercation Involving Racial Slurs
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation involving the use of racial slurs. One resident, with a diagnosis of bipolar disorder, was documented to have yelled a racial slur at another resident after being yelled at to leave the area. Both residents had a history of negative interactions, including police involvement. Despite documentation of the incident in nursing and social work notes, neither resident's care plan was revised to reflect the altercation or to address the new behavioral concerns that arose from the incident. Staff interviews revealed that direct care staff were unaware of any new interventions or changes to the care plans following the altercation. The care plans for both residents had not been updated to include the incident or to address the specific needs related to racial trauma and behavioral issues, as required by facility policy. The lack of care plan updates was confirmed by the Assistant Director of Nursing, who acknowledged that care plans should have been revised to document the incident and guide staff in preventing further occurrences.