Failure to Update Care Plans After Behavioral Incidents and Assessments
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the interdisciplinary team after each assessment for three residents. Specifically, the care plans were not updated to reflect new or ongoing behavioral issues, such as aggressive and physical behaviors towards other residents and wandering, despite documented incidents in the residents' progress notes. The care plans for these residents had not been updated with new interventions since their last revisions, even though there were multiple documented episodes of aggression and wandering that required staff intervention and, in some cases, resulted in hospital transfers. One male resident with severe cognitive impairment and a history of explosive disorder exhibited repeated aggressive behaviors, including hitting and shoving other residents, which led to another resident being sent to the emergency room. Despite these incidents, his care plan had not been updated with new interventions since the previous year. Another female resident with traumatic brain injury and dementia also demonstrated physical aggression, such as grabbing and slapping other residents, but her care plan interventions had not been revised since the previous year, even after multiple aggressive episodes were documented. A third male resident, also with severe cognitive impairment and a history of explosive disorder, was involved in a resident-to-resident altercation after wandering into another resident's room, resulting in a fall and injury. His care plan, which addressed wandering, had not been updated with new interventions since his admission, despite these incidents. The Director of Nursing confirmed that care plans should be updated after such events but was unable to explain why this had not occurred. Facility policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's condition or interventions.