Failure to Develop and Implement Comprehensive Care Plan for Resident Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting interventions for physical and verbally aggressive behaviors. The resident in question, an elderly female with Alzheimer's Disease and severe cognitive impairment, had documented incidents of both physical and verbal aggression toward others, as well as other behavioral symptoms such as wandering and inappropriate behaviors. Despite these behaviors being identified in assessments and incident reports, the care plan did not include specific interventions or measurable objectives to address the aggressive behaviors. Record reviews showed that the resident had a history of behavioral symptoms, including an incident where she attempted to strike another resident after a verbal altercation. Staff interviews confirmed that the resident was redirectable and that monitoring was implemented after the incident, but these interventions were not reflected in the resident's care plan. Multiple staff members, including LVNs, CNAs, ADONs, the MDS Coordinator, and the Administrator, acknowledged that the care plan should have been updated to include the resident's aggressive behaviors and appropriate interventions. The facility's own policy required the development and implementation of a person-centered comprehensive care plan to address each resident's medical, physical, mental, and psychosocial needs. However, the care plan for this resident did not include interventions for her aggressive behaviors, despite clear evidence from assessments, incident reports, and staff interviews that such behaviors were present and required management.