Failure to Update Care Plans After Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to update the care plans for two residents after incidents of abusive and aggressive behavior were observed. Specifically, after an altercation involving threats of physical harm between residents, including one resident making verbal threats and another responding with threats of their own, both individuals were placed on 1:1 supervision for the duration of the investigation. Despite documentation in the facility's incident report that care plans would be updated as appropriate, there were no updates made to the care plans of either resident to address the incidents or the observed behaviors. One resident, with a history of depression, anxiety disorder, and schizophrenia, was involved in an incident where they made verbal threats to another resident and later produced a small knife, refusing to surrender it to the DON and attempting to jab the nurse with it. This resident continued to display verbal outbursts and was eventually admitted to a behavioral health hospital due to being a danger to others and exhibiting increased aggression and violent behavior. The care plan for this resident did not reflect the incident involving the knife or the threats made to others. Another resident, with diagnoses including hypertension, aphasia following cerebral infarction, parkinsonism, and a history of traumatic brain injury, was reported to have verbally threatened another resident with bodily harm. The resident was separated from others and later evaluated by a mental health provider, who documented the resident's account of the incident and their understanding of the consequences of their behavior. However, the care plan for this resident was not updated to address the threats made. Interviews with facility staff revealed a lack of clarity and consistency regarding the process for updating care plans following such incidents.