Failure to Update Care Plan for Behavioral Management
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed the individual behavioral management needs of a resident with a history of alcohol abuse, adjustment disorder, depression, anxiety, and a below-the-knee amputation. The resident was moderately cognitively impaired and exhibited ongoing verbal and physical behavioral concerns, including threats toward staff and other residents, as well as inappropriate sexual behavior involving another resident. Despite multiple documented incidents, including verbal threats and inappropriate touching, the care plan was not revised to reflect these ongoing behaviors or to include individualized interventions to mitigate risk and ensure resident safety. Clinical record reviews and staff interviews confirmed that the care plan only addressed verbal aggression and a general desire for sexual expression, without incorporating specific strategies or updates related to the resident's repeated behavioral incidents, particularly those involving another resident. The Nursing Home Administrator and DON acknowledged that the care plan did not adequately reflect person-centered approaches or risk management strategies for the resident's interactions, resulting in a failure to meet regulatory requirements for comprehensive care planning.