Failure to Update Person-Centered Care Plans After Resident Incident
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents following a significant incident. For the first resident, who had a history of hemiplegia, hemiparesis, difficulty walking, and falls, multiple staff members reported that she was scared of her roommate after an incident in which the roommate was found standing by her bed, causing her distress and leading to a fall. Despite the resident expressing fear, pain, and a desire not to return to her room, the care plan was not updated to address her emotional response, safety concerns, or the interaction with her roommate. The second resident involved in the incident had diagnoses including metabolic encephalopathy and major depressive disorder, and experienced right arm numbness and sudden vision loss during the event. The care plan for this resident was also not updated to reflect the incident, her acute medical symptoms, or her actions during the event. Documentation showed that the resident had a severe headache, sudden blindness, and accidentally knocked down equipment, which contributed to the other resident's distress and fall. Interviews and record reviews confirmed that the facility's interdisciplinary team did not revise or implement care plans for either resident following the incident, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes after each assessment or significant event. The lack of updated care plans meant that the specific needs and responses of both residents were not addressed in their individualized plans of care.