Failure to Develop Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable goals and interventions for a resident with severe cognitive impairment, a history of delusions, and behavioral symptoms such as wandering, hitting, threatening, and screaming. The resident was known to enter roommates' personal living spaces, take their belongings, and display aggressive behaviors, but the care plan only addressed the risk of elopement and did not include interventions specific to these behaviors. Multiple incidents were reported where the resident invaded the personal space of roommates, leading to feelings of violation, anxiety, and, in one case, an allegation of bodily harm when the resident hit a roommate with a water bottle. Interviews and record reviews revealed that staff and administration were aware of the resident's behaviors but did not update the care plan to address the specific risks posed to other residents. Roommates and their responsible parties reported these incidents to staff and administration, but no effective measures were taken to prevent recurrence. Staff members described difficulty redirecting the resident and noted that the behaviors persisted over time, affecting multiple roommates and requiring intervention from more than one staff member on several occasions. The facility's own policy required the interdisciplinary team to develop and revise care plans as residents' conditions changed, including the implementation of person-centered interventions with measurable objectives. However, the care plan for this resident was not revised to address the ongoing behavioral issues, resulting in repeated incidents where the resident's actions negatively impacted the safety and well-being of other residents.