Failure to Update Care Plan for Aggressive Behavior and 1:1 Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's aggressive behavior and need for 1:1 supervision following significant changes in the resident's condition. On one occasion, the resident exhibited aggressive behavior, including spitting at a nurse, which resulted in a physician's order for 1:1 supervision. Despite this, a care plan reflecting the new intervention was not created or updated on the same day. Documentation and interviews confirmed that the care plan did not include the required interventions for aggressive behavior or 1:1 supervision at that time. Subsequently, the resident was transferred to a general acute care hospital for further evaluation due to increased agitation and aggression. Upon readmission to the facility, the care plan still lacked updates to address the resident's aggressive behavior and the need for 1:1 supervision. Multiple staff interviews, including those with LVNs, an RN, and the DON, confirmed that the care plan was not revised to reflect the resident's current needs and interventions after these significant events. Record reviews and staff statements indicated that the facility's policies and job descriptions required care plans to be updated with any significant change in a resident's condition or upon readmission from a hospital stay. However, these procedures were not followed, resulting in the absence of an accurate and current care plan for the resident during periods of behavioral escalation and after hospital readmission.