Failure to Review and Revise Care Plans After Resident Altercations
Penalty
Summary
Facility staff failed to review and/or revise care plans for two residents following resident-to-resident altercations. In the first instance, a resident with a history of traumatic brain injury, cognitive impairment, restlessness, agitation, mood disorder, and physical aggression was involved in an altercation where he punched another resident in the face. The incident resulted in the aggressor being placed on 1:1 supervision and the victim sustaining abrasions and undergoing neurochecks. Despite these events, there was no evidence that the care plan interventions for the aggressor were reviewed for effectiveness or revised after the incident. In the second case, another resident with dementia and a history of hoarding and physical aggression struck a peer in the chest as the peer attempted to pass by in a common area. Staff immediately separated the residents and placed the aggressor on 1:1 supervision. However, the care plan for this resident, which already noted aggressive behaviors, was not reviewed or updated following the altercation. Interviews with LPNs and a unit manager confirmed that care plans are intended to guide staff in meeting residents' needs and should be reviewed and updated after incidents such as physical altercations. Facility policy also requires care plans to be updated as changes occur and reviewed quarterly. Despite these requirements, there was no documentation of care plan review or revision for either resident following their respective incidents.