Failure to Update Care Plans for Behaviors and Monitoring Alert Systems
Penalty
Summary
The facility failed to update and implement comprehensive care plans for two residents with significant needs. For one resident with severe cognitive impairment and diagnoses including dementia, anemia, and hypertension, there were multiple documented incidents of physical and verbal behaviors towards another resident, including slapping. Despite these repeated behavioral incidents, the resident's care plan did not include any interventions or documentation addressing behaviors towards other residents. Interviews with facility management confirmed that care plans should be updated for behaviors, but this was not done for this resident. In another case, a resident with severe cognitive impairment and a history of heart disease, hypertension, and stroke exited through an exterior door, resulting in a fall and injuries. Following the incident, a roam alert bracelet was placed on the resident, but the care plan was not updated to include the use of the device, nor were there orders for monitoring the device or the resident's skin. Facility policy required care plans and monitoring for such devices, but these steps were not documented or implemented for this resident.