Failure to Develop Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to develop a person-centered care plan after a resident reported an abuse allegation to an LVN. The resident, who had a history of nontraumatic chronic subdural hemorrhage, schizophrenia, and depression, was assessed as having moderately impaired cognitive skills and lacking the mental capacity to make decisions. Despite the resident informing the LVN that staff had hit him and complained of scratches and bruises, the LVN assessed the resident and found no physical injuries. The LVN documented the incident in the progress notes but did not update or develop a care plan addressing the abuse allegation. The care plans reviewed for the resident did not include any interventions or guidance related to the reported abuse incident. The DON confirmed that care plans serve as a guideline for staff and should include immediate and ongoing interventions following an abuse allegation. The absence of a care plan meant there were no documented approaches or interventions for staff to follow in response to the resident's report, as required by the facility's policy on comprehensive, person-centered care planning.