Failure to Update Care Plans Following Behavioral Changes
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident with vascular dementia and severe cognitive impairment, the care plan did not address known behaviors such as stripping the bed and pulling down the privacy curtain, despite multiple incidents and staff awareness of these behaviors. Staff interviews confirmed that these behaviors had occurred more than once, and that the care plan had not been updated to reflect these safety-impacting actions. Another resident, diagnosed with schizoaffective disorder and major depressive disorder, experienced an episode of suicidal ideation, which resulted in her being sent to the emergency room for evaluation. Documentation and staff interviews revealed that this was the first such incident for this resident, and although she was receiving psychological services, her care plan was not updated to reflect the new behavior of suicidal ideation. The facility's policy required that such behavioral changes be care-planned, but this was not done following the incident. Record reviews and staff interviews indicated that the interdisciplinary team did not consistently update care plans to reflect significant changes in residents' behaviors or conditions. This lack of timely care plan revision could result in staff not having the necessary information to provide appropriate interventions, as documented in the facility's own policy and as acknowledged by administrative staff during interviews.