Failure to Update Care Plans After Falls and Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and/or revised for two residents following significant incidents. For one resident with end stage renal disease, hemiplegia, and pain, there was no documented evidence that the care plan was updated after a fall in the bathroom. The resident, who required assistance with mobility and transfers, was found on the floor after attempting to transfer to the toilet, resulting in complaints of pain and an X-ray being ordered. Despite the incident, the care plan was not revised to reflect the fall or to include new interventions, and staff interviews confirmed that the care plan update was not completed as required. Another resident with a history of cerebral infarction and moderate cognitive impairment exhibited multiple episodes of physical and verbal aggression, including throwing objects and attempting to hit staff. Progress notes documented these behaviors on several occasions, but there was no evidence that the care plan was reviewed or revised to address the ongoing aggressive behaviors. The lack of care plan updates following these incidents was confirmed through record review and staff interviews.