Failure to Revise Care Plan After Resident Aggression
Penalty
Summary
The facility failed to review and revise a resident's comprehensive care plan by the interdisciplinary team after each assessment, specifically following two incidents of aggressive and physical behaviors toward other residents. The care plan for a male resident with multiple psychiatric and cognitive diagnoses, including dementia, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, depressive episodes, and schizoaffective disorder, was not updated to reflect new or additional interventions after aggressive incidents occurred. The care plan in place included general interventions for behavioral symptoms and physical aggression, but did not address the specific incidents that took place on two separate occasions. Record review showed that after each incident, the resident was placed on one-to-one supervision and alternative placement was considered, but there was no evidence that the care plan was revised to include these interventions or to address the new behaviors. Interviews with facility staff, including the MDS Coordinator, Social Worker, DON, ADM, and ADON, revealed a lack of clarity and communication regarding responsibility for care plan updates. Staff acknowledged that care plans should be revised after incidents, but were unaware that the resident's care plan had not been updated following the aggressive events. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, as well as after incidents or changes in the resident's condition. The deficiency was identified through observation, interview, and record review, which confirmed that the care plan was not revised after the resident's aggressive behaviors. Staff interviews indicated that while incidents were discussed in meetings, the care plan was not formally updated to reflect the new interventions or changes in the resident's status. The lack of care plan revision was not attributed to any specific reason by the staff involved, and there was inconsistency in understanding who was responsible for making such updates.