Delayed Development and Implementation of Abuse-Related Care Plans
Penalty
Summary
The facility failed to develop and implement timely care plans for two residents following an incident of physical abuse, where one resident slapped another. Both residents had significant mental health diagnoses, including schizoaffective disorder, bipolar disorder, and paranoid schizophrenia. After the incident, the care plan categories for alleged abuse were initiated on the day of the event, but the specific goals and interventions were not created until five days later. For one resident, the interventions section remained blank. Multiple staff interviews confirmed that the care plan interventions should have been developed and implemented on the day of the incident to address the immediate needs and protection of the residents involved. Record reviews and staff statements indicated that the delay in developing and implementing the care plan interventions was not due to any reported electronic medical record (EMR) glitches, as the Medical Record Director was unaware of any such issues. The facility's policy requires that care plans be person-centered, targeted, and updated promptly when there is a significant change in a resident's condition. Despite this, the Interdisciplinary Team did not review or update the care plans in a timely manner after the incident, resulting in a deficiency related to delayed treatment and care planning for the affected residents.