Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents after significant incidents of resident-to-resident aggression. For one resident with Huntington's disease, bipolar disorder, major depressive disorder, schizoaffective disorder, and anxiety disorder, the care plan was not updated to reflect incidents where she was the recipient of aggressive behavior from another resident. These incidents included being hit and having her hair pulled, as well as being punched in the arm. Despite assessments and monitoring following these events, the care plan did not document these changes or add new interventions related to the aggression she experienced. Another resident, diagnosed with alcohol-induced dementia, psychosis disorder, COPD, diabetes mellitus, anxiety disorder, and depressive disorder, was involved as the aggressor in the same incidents. His care plan was also not updated to reflect his involvement in the aggressive behaviors, nor were new interventions or strategies documented to address these behaviors. Both residents had severely impaired cognition and required varying levels of assistance with daily activities and mobility, as documented in their assessments. Interviews with staff revealed that incidents and allegations were discussed in morning meetings, and the MDS Coordinator was responsible for updating care plans. However, the care plans for both residents were not revised after the incidents, and the DON acknowledged that she did not verify whether the updates had been made. The facility's policy required care plans to be reviewed and revised after a change in status, but this process was not followed, resulting in care plans that did not reflect the residents' current needs after the incidents.