Failure to Update and Implement Comprehensive Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans were not updated or revised to address significant changes in residents' conditions, including incidents of sexual and physical aggression, as well as abuse allegations. For example, one resident with schizophrenia, dementia, and impulse disorder exhibited repeated sexually inappropriate behaviors and aggression toward others, but the care plan was not updated to include interventions to prevent further incidents on several occasions. Another resident with Alzheimer's disease and major depressive disorder had multiple episodes of verbal and physical aggression toward other residents, including hitting and threatening, yet the care plan was not revised to reflect these behaviors or to implement new interventions after each incident. Several other residents who were victims of resident-to-resident aggression or abuse did not have their care plans updated to address their safety or to reflect the incidents they experienced. In one case, a resident was physically assaulted by another resident, but the care plan was not revised to include safety interventions. Another resident was subjected to inappropriate sexual behavior by a peer, but the care plan did not reflect this event or include measures to protect the resident. Additionally, a resident with significant cognitive impairment and multiple medical diagnoses was discharged before a comprehensive care plan was developed, despite the presence of a baseline care plan. Interviews with facility staff, including the ADON/MDS Coordinator, DON, and Administrator, revealed that care plan updates were delayed due to workload issues and staff covering multiple roles. Staff acknowledged that care plans should be individualized and revised promptly following incidents or changes in condition, but this was not consistently done. Facility policy required care plans to be developed within seven days of the MDS assessment and updated after significant changes, but these requirements were not met for several residents involved in incidents of aggression, abuse, or significant behavioral changes.
Removal Plan
- Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors by ADON/MDS nurse.
- ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely manner by the Administrator.
- Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates.
- MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due.
- DON has reviewed all care plans due dates and none are overdue.
- All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate.
- All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect.
- Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior.
- The administrator will monitor for compliance by being copied on emails to nurse's stations.
- All charge nurses have been notified of this new system by DON.
- Nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions.
- Staff were contacted and in-serviced by DON on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection.
- No staff will be allowed to work until this in-service is completed.