Failure to Initiate Care Plan After Resident Reports Feeling Threatened
Penalty
Summary
The facility failed to initiate a resident-specific care plan for a resident who verbalized feeling upset, angry, and threatened following an incident involving another resident's responsible party. The incident occurred when the responsible party demanded that the resident lower the volume on her phone, using a loud and threatening tone, which left the resident feeling scared, upset, and uncomfortable. Despite the resident's cognitive intactness and ability to participate in care planning, there was no care plan developed to address her psychosocial needs or to guide staff in monitoring her well-being during and after the incident. Record review and staff interviews confirmed that while some interventions, such as wellness checks, were implemented, there was no documentation of a comprehensive care plan with measurable objectives or timetables as required by facility policy. The Director of Nursing acknowledged that a care plan should have been created to ensure consistent interventions and staff awareness, but none was initiated. This omission meant that the resident's specific needs related to the incident were not formally assessed or addressed through the care planning process.