Failure to Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with appropriate interventions following an allegation of staff-to-resident abuse involving a resident admitted with diagnoses including diabetes, major depressive disorder, and hypertension. The resident, who had intact cognition as indicated by a BIMS score of 14 out of 15, reported to the social worker that a CNA was rough while assisting with bed mobility, describing being shoved into bed without being given the opportunity to move independently. The incident was documented in the facility's investigation summary, which noted the resident's desire for increased independence and the CNA's intent to prevent a fall. A review of the resident's care plan revealed that no updates or new interventions were added in response to the abuse allegation. The DON confirmed during an interview that the care plan was not revised after the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition or circumstances dictate. The lack of care plan update was identified during a survey and was found to be inconsistent with both facility policy and regulatory requirements.