Failure to Update and Implement Comprehensive Care Plans After Resident-to-Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents following incidents of resident-to-resident aggression and inappropriate sexual behavior. In several cases, care plans were not updated to reflect new or recurring behavioral incidents, nor were interventions added to prevent further occurrences. For example, after an incident where a male resident inappropriately touched a female resident, the care plan for the perpetrator did not include specific interventions to prevent further sexual abuse episodes, despite documentation of the event and its investigation. Additionally, care plans for residents who were either aggressors or victims in multiple resident-to-resident altercations were not revised to address their changing needs. One resident with a history of physical aggression was involved in several incidents with other residents, resulting in scratches, skin tears, and emotional distress. Despite these events, the care plans for both the aggressor and the victims were not promptly or adequately updated to include new interventions or strategies to mitigate future risks or address the impact of the incidents. The deficiency was further compounded by a lack of verification and follow-through in the care plan update process. The administrator acknowledged that while requests to update care plans were communicated via email to the MDS contractor, there was no system in place to ensure these updates were completed. This breakdown in communication and oversight resulted in care plans that did not accurately reflect the residents' current needs or the interventions required to ensure their safety and well-being, as evidenced by repeated incidents and confirmed findings in the facility's own investigations.
Removal Plan
- Resident #1's care plan was updated; psych NP discontinued Buspirone 5 mg with new order for Buspirone 20 mg every evening.
- Resident #2, #3 and #5 care plans updated regarding receiving abuse