Failure to Develop Person-Centered Care Plan for Behavioral Triggers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the behavioral triggers of a resident with severe cognitive impairment and a history of behavioral disturbances. The resident, who was readmitted with diagnoses including unspecified dementia with psychotic disturbance and unspecified psychosis, was known to have anger triggered by environmental factors such as roommates' televisions being on or loud noises. Despite this, the care plan did not include specific interventions or measurable objectives to address these triggers, as confirmed by the Director of Nursing during record review and interview. An incident occurred in which the resident with behavioral triggers became involved in a physical altercation with his roommate. The altercation began after the resident turned off his roommate's television, leading to a series of escalating actions that resulted in both residents sustaining injuries. Staff interviews and documentation indicated that the resident's behavioral response was directly related to his known triggers, yet no individualized care plan interventions had been implemented to prevent such incidents. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes to meet each resident's needs. However, the interdisciplinary team did not create a care plan specific to the resident's behavioral triggers, and no interventions were in place to address or mitigate these behaviors, contributing to the occurrence of the altercation.