Failure to Revise Care Plan After Repeated Resident-to-Resident Altercations
Penalty
Summary
The facility failed to revise the care plan for a resident with multiple behavioral health diagnoses, including schizophrenia, anxiety disorder, depression, restlessness, and agitation. Despite repeated incidents where the resident physically assaulted other residents, the care plan, which was initiated shortly after admission, was not updated with new interventions. Documentation showed that the resident was involved in multiple altercations, including hitting, grabbing, and causing injury to other residents over several months. Each incident was documented, and staff responded by separating residents and monitoring for further behaviors, but no new interventions were added to the care plan. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change. However, the care plan for this resident remained unchanged despite ongoing aggressive behaviors and documented incidents. The Director of Nursing confirmed that the care plan had not been updated and that the existing interventions were not effective in addressing the resident's behaviors.