Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation. One resident, with a history of dementia, neurogenic bladder, schizophrenia, and PTSD, became agitated and physically aggressive, ultimately striking another resident in the face. The altercation was documented in progress notes, and both residents were separated by staff before further escalation. Despite this incident, a review of the care plans revealed that neither resident's care plan was updated to reflect the altercation or to include interventions to address the event. Interviews with staff indicated that responsibility for updating care plans lies with the nurse in charge or the individual completing the incident report, but the care plans remained unchanged after the incident. The facility's policy requires a person-centered care plan to be developed and revised by an interdisciplinary team to address residents' needs and incidents, but this was not followed in the case of these two residents. Both residents had mild cognitive impairment and relevant medical conditions at the time of the deficiency.