Failure to Update Care Plan for Resident with Physical Behaviors
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a history of Parkinson's Disease and anxiety, who frequently exhibited physical behaviors resulting in self-harm and aggression towards staff. Despite the facility's policy requiring prompt assessment and care plan updates following changes in a resident's condition, the resident's care plan did not document her behavioral issues, known triggers, or interventions to reduce the risk of injury. Observations showed the resident was anxious, angry, and physically aggressive, including an incident where she sustained an open laceration and another where she struck a staff member while being assisted. Interviews with facility staff, including the nurse practitioner and the MDS coordinator, confirmed that the resident's mental state had declined and that the care plan had not been updated to reflect her current behaviors or needs. The lack of an updated care plan meant that staff were not provided with guidance on managing the resident's physical behaviors or preventing injury, despite multiple incidents and staff awareness of her triggers and risks.