Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to revise or update the care plan for a resident after an incident involving physical aggression. According to the facility's policy, care plans must be reviewed and revised to reflect changes in a resident's status. A resident with severe cognitive impairment, paranoid schizophrenia, and a history of physical aggression was involved in an altercation with another resident, during which he struck the other resident multiple times. Despite this incident, there was no documented evidence that the care plan was updated to include new interventions to prevent similar future incidents. Review of clinical records and staff interviews confirmed that the care plan for the resident with a history of aggression had not been revised following the altercation. The Nursing Home Administrator indicated uncertainty about what additional interventions could be implemented, but acknowledged that the care plan had not been changed after the event. This failure to update the care plan was identified during the survey as a deficiency in compliance with regulatory requirements.