Failure to Update Care Plan Interventions Following Resident-to-Resident Aggression
Penalty
Summary
Facility staff failed to update care plan interventions for a resident with a known history of aggressive behaviors, resulting in two separate staff-witnessed incidents where this resident acted aggressively toward another resident. The first incident involved one resident hitting another on the shoulder while being escorted to the hair salon. The affected resident displayed pain cues but denied pain or discomfort upon assessment, and no physical injuries were observed. The care plan for the resident who was hit was updated to include monitoring for injury and providing emotional support, but the care plan for the resident who exhibited aggression was not revised with new interventions to prevent further incidents. The resident with aggressive behaviors had a documented history of Alzheimer's Disease, depression, and agitated dementia, and was already under psychiatric care for these behaviors prior to the incidents. Medical records and psychiatric notes indicated ongoing issues with aggression, particularly after lunch, and described the resident as having a quick temper and being physically aggressive at times. Despite these documented behaviors and the occurrence of the first incident, there was no evidence that the care plan was updated with new approaches or interventions to address the risk of further aggression toward the other resident. A second incident occurred in which the same resident was reported to have slapped the other resident on the face. Staff investigation found that a threat was made, but no physical contact was confirmed by witnesses. The care plan for the resident who was threatened was updated to include monitoring and a psych consult, but again, the care plan for the resident with aggressive behaviors was not revised with new interventions after this second event. The Director of Nursing acknowledged during interview that the care plan should have been updated with new approaches after each incident, but this was not done.