Failure to Timely Review and Revise Care Plan After Resident Altercation
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews, as required by facility policy. Specifically, a resident with diagnoses of dementia, major depressive disorder, and agitation was assessed as having severely impaired cognition, wandering behavior, and agitation. The resident's comprehensive care plan was developed and later revised, but not in response to a significant incident. After a quarterly assessment documented the resident's ongoing behavioral issues, the resident was involved in a physical altercation with another resident following wandering into another room. Despite this incident, the care plan was not reviewed or updated to reflect new interventions until several months later. Record review and staff interviews confirmed that no new interventions were implemented following the altercation, and the behavior care plan remained unchanged. The facility's policy required care plans to be updated to reflect episodic issues or problems as they arise, including after significant changes in a resident's condition or behavior. Staff interviews revealed that the responsibility for updating the care plan was not clearly followed, as the nurse who completed the incident report did not update the care plan, and the behavior care plan was not reviewed or revised in a timely manner after the incident.