Failure to Update Care Plan After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to update a resident's care plan following an incident of abusive behavior involving two residents. According to the facility's policy, care plans are to be revised as new information about a resident's condition becomes available, and interventions should address the underlying sources of problem areas. Despite this, after an incident where a resident with non-Alzheimer's dementia and intact cognition was observed pushing another resident and attempting to tie a neck pillow around their neck, no updates or new interventions were added to the resident's care plan. The incident was reported to the appropriate authorities, and immediate actions were taken to separate the residents and provide one-on-one supervision for the resident involved in the abusive behavior. A review of the resident's care plan, last revised after the incident, showed no documentation of the behaviors or any new interventions related to the event. The MDS coordinator confirmed that the care plan was not updated following the incident, despite facility policy requiring updates after significant changes in a resident's health or behavior. The lack of care plan revision occurred even though the resident's assessment indicated ongoing cognitive and behavioral concerns.