Failure to Revise Care Plan After Repeated Aggressive Incidents
Penalty
Summary
The facility failed to review and revise the care plan for a resident with multiple psychiatric diagnoses, including paranoid schizophrenia, mood disorder, post-traumatic stress disorder, brief psychotic disorder, and depression. The resident was involved in multiple incidents of aggressive behavior and abuse toward other residents, as documented in incident reports dated 09/26/24, 10/26/24, and 01/10/25. These incidents included physical altercations such as kicking and hitting other residents, resulting in law enforcement involvement and transfers for psychological evaluation or inpatient treatment. Despite these repeated incidents, the care plan for the resident was not updated with new interventions following the most recent episode of aggression. Instead, the care plan relisted previously implemented interventions without introducing any new strategies to address the ongoing problem of agitation and aggressive behavior. The care plan coordinator confirmed that no new interventions were added after the latest incident, acknowledging that new interventions should have been implemented if the behaviors persisted.