Failure to Update Care Plans for Aggression and Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation and facility policy. For one resident with diagnoses including Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, and Cognitive Communication Deficit, the care plan did not address incidents of verbal abuse or threats toward another resident. Documentation showed that this resident was involved in a physical altercation, where she was observed hitting another resident with an object, resulting in injuries. Despite these behaviors and prior reports of paranoia, the care plan lacked interventions or measurable objectives to address the resident's aggressive and threatening behaviors. Another resident, with a history of Dementia, Major Depressive Disorder, PTSD, and Anxiety Disorder, exhibited multiple episodes of suicidal ideation and self-harm attempts. Progress notes documented several incidents where the resident expressed a desire to die, attempted to harm herself with objects such as scissors and a stapler, and required intervention from staff, police, and emergency medical services. However, the care plan for this resident did not include any interventions or objectives related to suicidal ideation or self-harm, despite these repeated and documented behaviors. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans following significant changes in resident condition or behavior. The MDS Nurse, ADON, and Administrator each described different understandings of who was responsible for ensuring care plans were updated to reflect acute issues such as suicidal ideation or resident-to-resident aggression. The facility's own policy required timely and comprehensive care planning, including measurable objectives and timeframes, but these requirements were not met for the residents involved.