Failure to Timely Revise Care Plan for Escalating Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised in a timely manner to address ongoing and escalating aggressive behaviors. According to facility policy, care plans must be updated whenever there are changes in a resident's condition, not just during quarterly reviews. Resident R1, who had diagnoses including dementia, seizure disorder, and malnutrition, exhibited a series of aggressive behaviors over several weeks, including raising a cane toward a roommate, striking a nurse, verbally abusing staff, and ultimately striking another resident with a cane. Despite these documented incidents, the care plan was not reviewed or revised until after multiple aggressive episodes had occurred. Facility documentation and staff interviews confirmed that the interdisciplinary team was aware of the resident's behavioral changes and was informally monitoring the situation, but no formal updates were made to the care plan until after a significant incident. The care plan was only revised to include a psychiatric consult following the escalation of aggressive behaviors. Prior to these events, the resident was not considered a behavioral risk and had no documented history of aggression. The delay in updating the care plan did not align with facility policy, which requires prompt revisions in response to significant changes in a resident's status.