Failure to Update Care Plan for Ongoing Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address ongoing verbal behavioral symptoms for a resident with a history of dementia and generalized anxiety disorder. Despite multiple documented incidents of the resident yelling, being disruptive, and directing verbal outbursts toward others, there was no evidence that the care plan included goals or interventions to manage these behaviors. The facility's own policy required that care plans be developed and revised as needed to reflect the resident's current needs, but this was not done in this case. Progress notes over a two-month period detailed repeated episodes where the resident yelled for staff to call their spouse, was disruptive to other residents, and had conflicts with a roommate. Staff interventions included calling family members, attempting redirection, and moving the resident to different locations, but these actions were not formalized in the resident's care plan. The Minimum Data Set (MDS) assessment triggered the need for care planning related to behavioral symptoms, yet the care plan remained unchanged and did not address the ongoing issues. Interviews with facility staff, including an LPN, the MDS Coordinator, the Medical Director, the DON, and the Social Services Director, confirmed that the care plan should have been updated to include interventions for the resident's behaviors. The lack of care plan updates persisted despite clear evidence of recurring behavioral symptoms and staff awareness of the problem. The deficiency was identified through interviews, record reviews, and policy review, all of which indicated a failure to follow established procedures for care planning.