Failure to Develop and Implement Comprehensive Behavioral Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that accurately reflected the behavioral needs of multiple residents. Specifically, for 11 out of 14 residents reviewed, care plans did not address aggressive behaviors that were documented in progress notes and other records. In several cases, residents with histories of physical and verbal aggression towards staff and other residents did not have these behaviors reflected in their care plans, or the interventions listed were not updated to address recent incidents. For example, one resident with severe cognitive impairment and a history of aggressive outbursts, including physically harming other residents, had a care plan that was not revised to reflect these behaviors or to include specific, measurable interventions. Another resident with a diagnosis of schizophrenia and a documented incident of hitting another resident had no mention of aggressive behaviors in the care plan. Similar omissions were found for other residents with documented incidents of physical aggression, including pushing, hitting, and inappropriate sexual contact, none of which were adequately addressed in their respective care plans. The lack of updated and individualized care plans meant that staff did not have clear, actionable guidance to manage and prevent further aggressive incidents. The documentation showed repeated episodes of resident-to-resident and resident-to-staff aggression, with care plans either missing, outdated, or lacking specific interventions tailored to the residents' current behavioral needs. This failure to maintain accurate and comprehensive care plans was identified as a deficiency by surveyors, as it did not meet regulatory requirements for ensuring residents' highest practicable physical, mental, and psychosocial well-being.