Failure to Update Care Plan After Abuse Allegation
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following an allegation of abuse. Specifically, a resident with diagnoses including hypertension and bipolar disorder, and with intact cognition, reported to the Social Worker that they were hit on the head and pushed to the ground by a Certified Nursing Assistant. The incident was documented in the facility's Accident/Incident Report, and an investigation was conducted, concluding that the abuse allegation was inconclusive. Despite this significant event, the resident's care plan, which previously included interventions for risk of abuse, was not updated to reflect the new allegation or its outcome. Record review showed that no new interventions had been implemented since before the incident, and the care plan had not been revised since the previous update. Interviews with facility staff, including the DON and a Registered Nurse Supervisor, confirmed that the care plan was not updated due to oversight. The facility's own policy requires care plans to be revised to reflect current needs based on incidents such as accidents or behavioral changes, but this was not followed in this case.