Failure to Develop Comprehensive Care Plan Addressing Abuse Risk
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically regarding risk for abuse. The resident in question had multiple diagnoses, including pyogenic arthritis, depression, and bipolar disorder, and was cognitively intact but physically impaired, requiring assistance with mobility, transfers, and toileting. Despite these vulnerabilities, there was no documented evidence that a care plan addressing risk for abuse was in place prior to an alleged incident in which the resident reported that a certified nurse aide threw a television remote at them, striking them in the face. The facility's policy required that a comprehensive care plan be developed within 14 to 21 days of admission, but review of the records showed that the risk for abuse care plan was not initiated until after the alleged incident occurred. Prior to this, the only care plan in place addressed communication needs, with interventions to anticipate and validate the resident's needs. The lack of a timely and comprehensive care plan addressing abuse risk constituted a failure to meet regulatory requirements.