Failure to Update and Document Changes in Resident's Care Plan
Penalty
Summary
The facility failed to follow its policy and procedure for care plan documentation for one resident when the care plan was not updated to reflect changes in the resident's condition and behaviors. Specifically, a resident with a history of subdural hemorrhage, aphasia, and dementia exhibited increased aggressive behaviors, including yelling, slamming doors, and inappropriate interactions with another resident. Despite these changes, the care plan was not updated, and nursing staff did not document the resident's outbursts or aggressive behaviors as required by the facility's policy. The last documented update in the care plan was several weeks prior to the observed incidents. Interviews with staff confirmed that the resident's care plan should have been updated to reflect the recent behavioral changes, and that documentation of each outburst or aggressive behavior was not completed as per policy. The Director of Nursing acknowledged that the policy regarding care plan documentation was not followed, emphasizing the importance of timely updates and documentation to ensure effective communication among staff.