Failure to Update and Individualize Care Plans After Resident Altercation and Inconsistent Smoking Assessments
Penalty
Summary
The facility failed to update and individualize the comprehensive person-centered care plans for two residents following a resident-to-resident altercation. Despite an incident in which one resident alleged being hit by another in the courtyard, the care plans for both individuals were not revised to include new, specific interventions to prevent further abusive situations. The care plans contained previously initiated interventions, such as using separate courtyard doors, which had not been effective in preventing the altercation. Staff interviews confirmed that while verbal education and separation of the residents were implemented, these actions were not documented or reflected in the residents' care plans. Additionally, inconsistencies were found between the residents' care plans and their smoking risk assessments. For one resident, the care plan indicated the need for supervised smoking due to unsafe behaviors, but the smoking risk assessment allowed the resident to keep their own smoking materials and did not clarify the supervision requirements. The other resident's care plan required supervision and staff-secured smoking materials, yet the risk assessment indicated the resident could smoke without supervision and keep their own materials. These contradictions were not addressed or reconciled in the care plans or assessments, and no updates were made following the most recent assessments or incidents. The facility's own policies require that care plans be updated after significant changes in a resident's condition or after incidents such as altercations. However, the care plans for both residents did not reflect the interventions discussed by staff or the outcomes of the facility's investigations. The lack of timely and individualized updates to the care plans, as well as the inconsistencies between assessments and care plan interventions, contributed to the deficiency identified by the surveyors.