Failure to Update Care Plans and Document Incidents After Resident Altercations and Abuse Allegation
Penalty
Summary
The facility failed to ensure that care plans were updated and documentation was complete for three residents following significant incidents. Two residents were involved in a resident-to-resident altercation in the smoking area, where one resident, who was cognitively intact and had diagnoses including ALS and dysphagia, reported being struck in the face by another resident. The other resident involved had severe cognitive impairment, hemiplegia, and aphasia, and was unable to provide a personal account of the incident. Despite the altercation being reported and documented in progress notes and communication forms, neither resident had a care plan initiated or updated to address the incident. Additionally, another resident with moderate cognitive impairment, COPD, bipolar disorder, and adult failure to thrive, reported being pushed against the wall by a CNA during a brief change. This incident was reported as suspected abuse, but there was no documentation in the clinical record regarding the event, and no care plan was initiated to address the situation or the resident's needs following the report. Interviews with facility leadership confirmed that these incidents were not reflected in the residents' care plans and that documentation in the clinical records was incomplete or missing. Facility policies require that care plans be updated and incidents documented when there is a significant change in a resident's condition or following an altercation or abuse allegation, but these procedures were not followed for the residents involved.