Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents following significant changes in their conditions after two resident-to-resident altercations. Despite documented incidents where one resident physically assaulted another, resulting in physical and psychosocial harm, the care plans and Kardex for both residents were not updated to include interventions to prevent recurrence, such as separation or increased monitoring. Staff interviews confirmed that interventions were limited to informal redirection rather than documented, individualized strategies. Both residents involved had intact cognition, as indicated by BIMS scores of 15, and diagnoses including anxiety and mood disorders. The first altercation involved one resident pushing and kicking another, while the second incident escalated to physical violence and threats, resulting in one resident sustaining blunt trauma to the nose and expressing fear and distress. Despite these events, there was no documentation in the care plans or Kardex to guide staff in preventing further incidents, and staff were unaware of any specific interventions or risks related to these residents.