Failure to Update Care Plans After Resident-to-Resident Aggression
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents following incidents of resident-to-resident aggression. Each of these residents had documented episodes of physical aggression toward other residents, which were not subsequently addressed in their care plans through updated goals or interventions. Despite the incidents being discussed in daily and weekly meetings, the care plans were not revised to reflect the new behavioral concerns, and the necessary interventions were not documented for staff reference. For the first resident, who had diagnoses including dementia and intermittent explosive disorder, an incident of aggression occurred, and while immediate actions such as Q15 minute monitoring and provider notification were taken, the care plan was not updated to address the aggressive behavior. The second resident, with Alzheimer's and a history of behavioral symptoms, also exhibited aggression toward another resident. Although this resident's care plan included a general focus on behavioral symptoms, it was not revised to specifically address the new incident of aggression or to add targeted interventions. The third resident, who had multiple psychiatric diagnoses and was hard of hearing, was involved in an altercation where he struck another resident. While staff responded by separating the residents and implementing monitoring, the care plan was not updated to reflect the incident or to include new strategies for managing such behaviors. Interviews with facility staff and leadership confirmed that the incidents were discussed but not thoroughly documented in the care plans, and there was a lack of clarity regarding responsibility for timely care plan revisions following behavioral incidents.