Care Plan Not Updated After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following both comprehensive and quarterly assessments, as required. Specifically, after a resident with severe cognitive impairment and a history of dementia and anxiety disorder was involved in a physical altercation with another resident, the care plan was not updated to reflect this incident of resident-to-resident aggression. The care plan did not include any interventions or documentation related to aggression or altercations, despite the occurrence of a significant behavioral event. Interviews with facility staff revealed that although the incident was discussed in morning meetings and the care plan for the other resident involved was updated, the care plan for this resident was not revised. The MDS Coordinator responsible stated that because the resident did not experience psychological trauma or significant physical injury, the care plan was left unchanged. Facility policy required the care plan to be revised to address changes in behavior and care, but this was not followed in this case.