Failure to Implement Care Plan Intervention for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of physical aggression towards others. The care plan, established due to previous incidents, required staff to monitor the resident and keep him separated from other residents in the dining area. Despite this intervention being documented and known to staff, the resident was able to physically touch another resident on the jaw with a closed fist during a meal. Multiple staff interviews confirmed awareness of the care plan requirement, but acknowledged that the intervention was not followed at the time of the incident. The resident involved had diagnoses including schizoaffective disorder, bipolar disorder, and adjustment disorder, and had previously exhibited physically aggressive behavior. The other resident involved had developmental and mental health diagnoses. The incident was witnessed by a visitor, reported to staff, and resulted in the residents being separated, with no injuries noted. Facility policy required comprehensive care plans to be implemented and for staff to be notified of their responsibilities, but this was not carried out in this instance, leading to the deficiency.