Failure to Update Care Plans After Verbal Abuse Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for three residents following incidents of verbal abuse by staff members. For one resident, after reporting that a dietary cook yelled, argued, slammed a door, and used profane language, there was no documentation in the care plan reflecting the incident or any related interventions. The resident was cognitively intact, as indicated by a BIMS score of 14, and the incident was reported to the nurse practitioner, responsible party, and local police, with the staff member suspended. However, the care plan remained unchanged, and interviews with facility staff confirmed that care plans were not reviewed or updated after such incidents. Similarly, two other residents experienced verbal abuse from an LPN, including being yelled at and told to "shut up." Written statements documented these events, but reviews of their comprehensive care plans showed no evidence of review or revision following the incidents. Staff interviews further revealed a lack of understanding or adherence to the policy requiring care plan updates when changes in a resident's condition or circumstances occur, such as after abuse allegations. The administrator and director of nursing were made aware of these concerns, but no additional information was provided before the survey exit.