Failure to Timely Update Care Plan for Resident Aggression
Penalty
Summary
The facility failed to ensure that the care plan for a resident with multiple psychiatric and neurological diagnoses, including unspecified dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder-bipolar type, was revised to address the resident's verbal and physical aggression towards others. The resident was admitted with severe cognitive impairment, as indicated by a BIMS score of 5, and exhibited verbal behavioral symptoms directed toward others 4 to 6 days a week, as documented in the quarterly MDS assessment. Despite this, the care plan dated October 17, 2024, did not include interventions for these behaviors, focusing instead on social and emotional needs. Clinical record review and staff interviews revealed that the resident had documented incidents of verbal aggression, including yelling at and threatening another resident. However, there was no evidence that the interdisciplinary team (IDT) had reviewed the quarterly MDS assessment for behaviors or updated the care plan accordingly at that time. The care plan was not revised to include behavioral interventions until September 11, 2025, despite ongoing documentation of aggressive behaviors in the clinical record. Interviews with nursing staff, the MDS nurse, the assistant director of nursing, and administrative staff confirmed that the behavioral symptoms were identified in the MDS and clinical records but were not transferred to the care plan in a timely manner. Staff acknowledged that the lack of behavioral interventions in the care plan could impede behavior identification, de-escalation, and communication among staff. Facility policy required the comprehensive care plan to be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment, which was not followed in this case.