Failure to Implement Care Plan for Resident with Behavioral Issues
Penalty
Summary
Staff failed to implement the care plan for a resident with a history of verbally abusive behaviors related to poor impulse control. The care plan included interventions such as gentle redirection when applicable. On the day of the incident, staff observed the resident invading another resident's personal space, appearing angry and aggressive, but did not intervene. This inaction allowed the resident to escalate, resulting in cussing at and physically hitting the other resident on the leg, as well as throwing the resident's belongings on the floor. Documentation and interviews confirmed that the resident had a moderately impaired cognitive status and had previously exhibited similar behaviors, including yelling and becoming upset with the roommate. Staff members present at the time either did not intervene or delayed intervention, despite being aware of the resident's behavioral history and the care plan interventions. The facility's policy required individualized behavioral interventions to address such behaviors, but these were not implemented during the incident.