Failure to Update Care Plans for Residents with Behavioral and Vulnerability Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current care needs of two residents. One resident with dementia and severe cognitive impairment exhibited verbally aggressive behaviors towards both staff and his roommate, including yelling, cussing, and making threats. Despite these documented behaviors in nurse progress notes, his care plan did not include any mention of his aggressive behaviors or interventions for staff to address these issues. Additionally, an alarm was placed on this resident, but the care plan did not specify the type, location, or purpose of the alarm. Another resident, who was cognitively intact and did not have mental health diagnoses, was vulnerable to verbal aggression from her roommate. Nurse progress notes indicated that her roommate had been observed to holler at her, and her family was aware of the situation. However, her care plan did not address her vulnerability or include interventions to limit her exposure to verbal aggression. Both the director of social services and the DON confirmed that the care plans for these residents were not updated to reflect their current needs, citing a lapse in communication and responsibility between staff members.