Failure to Update Care Plans After Behavioral and Safety Incidents
Penalty
Summary
The facility failed to develop and implement complete, individualized care plans with measurable objectives and timetables for multiple residents following significant behavioral incidents. One resident with a history of dementia, anxiety, altered mental status, and intellectual disabilities ingested plastic wrap from a dessert cup during a meal. Despite a documented history of ingesting inedible items, the resident's care plan was not updated to address the most recent incident, nor did it include new interventions or services to mitigate the risk of recurrence. Staff interviews confirmed that the care plan did not reflect the incident or provide updated strategies for prevention. Two other residents, both with cognitive impairments and psychiatric diagnoses, were involved in incidents of inappropriate sexual contact, including being found naked together in bed and engaging in physical contact. Their care plans did not include goals or interventions to address these behaviors, despite repeated incidents and documentation in progress notes. Staff interviews revealed that the care plans were not updated to reflect these behaviors, and there was no documentation of interventions to prevent further inappropriate contact or to address the residents' inability to make consensual decisions. The facility's policy required care plans to be reviewed and revised quarterly, upon status changes, or as necessary, with updates to interventions as needed. However, the care plans for these residents were not revised in a timely manner following the incidents, resulting in a failure to provide appropriate, individualized care and services as required. The deficiency was identified as Immediate Jeopardy due to the lack of updated care plans with measurable objectives and timeframes after significant behavioral events.