Failure to Revise Care Plan for Resident's Environmental Needs Resulting in Fatal Altercation
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a known preference for a quiet environment, despite documented behavioral risks and multiple room changes. The resident had a history of dementia, severe cognitive impairment, and was a registered sex offender on parole, monitored with an ankle bracelet. The care plan did not address the resident's need for a quiet room, even though staff were aware of his agitation triggered by noise and previous incidents involving other roommates. Another resident, who also had dementia, severe cognitive impairment, and was receiving hospice care, was placed in the same room. This resident exhibited frequent shouting and disruptive behaviors, which were documented in his care plan. Despite these known behaviors, the care plan for the first resident was not updated to reflect the risk posed by being housed with a noisy roommate, nor were interventions implemented to mitigate this risk. As a result, an altercation occurred in which the first resident assaulted the second resident, leading to severe injuries including lacerations, facial fractures, rib fractures, and a vertebra fracture. The injured resident was transferred to a hospital and subsequently expired. Interviews with staff confirmed that the care plan should have been revised to address the resident's preference for a quiet environment and to assess risks during room changes, but this was not done.