Failure to Timely Update Care Plan After Abuse Incidents
Penalty
Summary
The facility failed to timely revise and update the care plan for a resident following multiple incidents of abuse. According to the facility's policy, care plans must be revised as information about the resident and their condition changes, and the interdisciplinary team is required to review and update the care plan when desired outcomes are not met. In this case, a resident with severe cognitive impairment and a diagnosis of sexual dysfunction was involved in several incidents of sexually inappropriate behavior, including grabbing staff and making sexual comments. Although the care plan was initially created and later revised, documentation showed that updates were not made promptly after each incident as required. Record review and staff interviews revealed that incidents occurring on specific dates were not reflected in the care plan until several days later. The MDS coordinator acknowledged that care plans were typically updated every three months and as necessary, but admitted that updates for certain incidents were delayed. The coordinator also confirmed that they were solely responsible for updating care plans and recognized that the care plan should have been updated sooner following the incidents of abuse.