Failure to Update Care Plan After Psychosocial Incident Involving Family Member
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Parkinson's Disease, despite significant psychosocial events involving the resident's son. The resident, who was cognitively intact as indicated by a BIMS score of 13, experienced two incidents where his son displayed disruptive and hostile behaviors, including verbal aggression and vulgar language toward staff in the resident's presence. On one occasion, law enforcement was required to intervene, resulting in the son being handcuffed and removed from the facility, after which he was prohibited from entering the building. Despite these events, a review of the resident's care plan revealed no evidence that the resident's psychosocial well-being had been evaluated or addressed in relation to the incidents or the subsequent restriction of his son's visitation. Interviews with the Social Worker and the Director of Nursing confirmed that the care plan was not updated to include ongoing assessment of psychosocial needs or related goals following these incidents. This failure was not consistent with the facility's policy, which requires individualized care plans to be revised as information about the resident and their condition changes.