Failure to Update Care Plan After Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan following a resident-to-resident altercation involving a resident with significant medical and cognitive conditions. The resident, who had diagnoses including anoxic brain damage, alcohol dependence, anxiety disorder, and type II diabetes mellitus, was observed in the hallway yelling and grabbing another resident's arm. Despite this incident, there was no care plan entry created to address the altercation or to outline interventions to prevent recurrence or address the resident's needs. Record review and interview with the DON confirmed that the interdisciplinary team typically updates care plans after incidents, but in this case, no such update was made. Facility policies require that care plans be reviewed and revised upon a resident's status change, and that the interdisciplinary team collaborates on intervention options. However, these procedures were not followed, resulting in the absence of documented interventions or updates to the resident's care plan after the altercation.