Failure to Update Care Plans for Documented Resident Behaviors
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately reflected the documented behaviors of two residents with dementia and behavioral disturbances. For one resident with Alzheimer's disease, dementia, and psychotic disorder, multiple progress notes documented repeated incidents of aggression and resistiveness toward staff, including attempts to hit, grab, punch, and throw objects at staff and other residents. Despite these documented behaviors and medication adjustments for agitation, the resident's care plan did not include a comprehensive plan addressing these specific behaviors. Another resident with dementia and generalized anxiety was noted in progress notes to have demonstrated physically aggressive and resistive behaviors, including punching another resident. However, the care plan for this resident did not document the behavior or address the risk for aggression toward other residents. Facility guidelines require that new areas of concern, such as these behaviors, be addressed in the care plan, but this was not done for either resident.