Failure to Develop and Communicate Baseline Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a history of aggressive and paranoid behavior. Despite the resident being admitted with diagnoses including dementia and a documented chief complaint of aggression and paranoia, the baseline care plan did not address these behavioral concerns. There was also no evidence that the resident or their representative received a summary of the baseline care plan, as required by facility policy. Multiple staff interviews confirmed that the baseline care plan was either incomplete or not provided to the family, and that behavioral issues were not addressed because staff did not perceive them at the time of admission. As a result of these omissions, the resident physically assaulted another resident with a wheelchair footrest, leading to the second resident's hospitalization and subsequent death. Documentation and interviews revealed that the facility's process for reviewing admission documents, completing assessments, and distributing care plan summaries was not consistently followed. The lack of a comprehensive, person-centered baseline care plan and failure to communicate it to the resident and their family directly contributed to the incident.