Failure to Update Care Plans Following Resident Aggression
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four out of eleven residents following incidents of aggression or behavioral changes. For one resident with a history of psychosis, insomnia, and major depressive disorder, an altercation with a roommate involving threats and aggressive behavior was documented. Despite this incident, the resident's care plan was not updated to address the new aggression, and no new interventions were added. The last care plan revision occurred months prior to the incident, and no additional care plan addressing aggression towards other residents was found in the electronic medical record. Two other residents were involved in a physical altercation after a disagreement over a room light. Both residents engaged in shoving and striking each other, and one was subsequently moved to another room. However, neither resident's care plan was updated to reflect the aggressive behavior or to include interventions to prevent further incidents. The care plans for both residents had not been revised since before the incident, and no new interventions addressing aggression were documented. Another resident was observed pushing his wife, also a resident, in her wheelchair and using physical force while shouting at her. The incident included yelling, grabbing, and striking, resulting in the wife being moved to another room. Despite this, there was no care plan created or updated to address the resident's aggression or the change in living arrangements. Interviews with facility staff confirmed that care plans should have been updated following these incidents, but the updates were not completed, and staff could not explain why the care plans were missed.