Failure to Develop and Implement Comprehensive Behavioral Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan addressing behavioral issues for one resident. Clinical record review showed that the resident was admitted with behaviors such as refusal of care and agitation, which were identified in the Minimum Data Set Assessment. Although a care plan was initiated, there was no documented evidence of specific interventions for staff to use when the resident exhibited these behaviors. The care plan was later updated to include additional behaviors such as slapping and being combative, but still lacked individualized interventions for staff guidance during care. Nursing documentation revealed multiple incidents where the resident displayed aggressive behaviors, including biting, kicking, spitting, and being combative with staff during care activities. These incidents required significant staff intervention, including the involvement of four staff members to provide incontinence care. Despite these documented behaviors, the care plan did not reflect any individualized strategies or interventions to address or manage the resident's actions. The deficiency was confirmed during an interview with the Administrator and DON.