Failure to Update Care Plan for Resident with Pain and Aggression
Penalty
Summary
The facility failed to review and revise the care plan for a resident with chronic pain and dementia with agitation, despite multiple documented incidents indicating changes in the resident's condition. The resident's medical record showed 21 instances of pain or requests for pain medication, two occasions of verbal or physical aggression with other residents, and 23 occasions of verbal or physical aggression with staff over a period of approximately two months. The current care plan did not include problems, goals, or interventions addressing the resident's pain or aggressive behaviors. During staff interviews, administrative staff confirmed that the care plan required updates and revisions to reflect the resident's current status. Additionally, the facility was unable to provide a copy of their care plan policy when requested.