Failure to Monitor and Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for one resident who experienced a change in condition characterized by aggressive behavior. The resident, who had the capacity to make medical decisions, was observed barricading himself in his room, yelling, and posing a danger to himself and others. The licensed nurse administered IM Ativan as ordered and indicated that the resident would be monitored closely for safety. However, there was no documented evidence that the resident's change in condition was monitored every shift for 72 hours as required by facility policy. Progress notes and the eINTERACT Change of Condition Report confirmed the aggressive episode, but subsequent monitoring was not documented in the medical record. Additionally, the resident's care plan, which previously addressed a mood problem, was not revised to include new interventions or monitoring related to the recent episode of physical aggression. Review of the care plan and interviews with nursing staff confirmed that the care plan was not updated to reflect the resident's change in condition. The facility's policy required care plan revisions upon a status change, but this was not followed in this instance. The Administrator and DON acknowledged these findings during the survey.