Failure to Implement Behavior Care Plan to Prevent Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to consistently implement an existing behavior care plan for a resident with a known history of poor impulse control and aggression. The resident was an adult, alert and able to make their own decisions, with multiple diagnoses including end stage 5 kidney disease, alcohol use, PTSD, anxiety disorder, schizoaffective disorder, chronic migraine, diabetes, depression disorder, and heart failure. The resident required assistance with ADLs, had a left below-knee amputation, was wheelchair-bound, and received dialysis. The resident’s care plan for potential aggression, dated 1/14/25, directed staff to avoid confrontation and adjust the plan of care to reduce incidents of aggression where possible. The facility’s care plan policy required that care plans be specific, resident-centered, and address management of risk factors, including aggressive behaviors. On 1/7/26, an argument occurred between this resident and another resident regarding an accusation of theft, leading the facility to initiate 15-minute checks for the aggressive resident. Despite this known conflict and the active aggression care plan, on 1/8/26 staff allowed the resident to sign out for a smoking LOA at a time when they were aware the other involved resident was already outside. Video and documentation showed that as the resident wheeled past the other resident, the other resident struck them with a grabber, and both residents then hit each other, with the aggressive resident striking the other resident’s face and causing a cut. The 15-minute check sheet documented observation of the resident at 11:45 a.m. while outside, during the period of the altercation. In interviews, the Administrator and DON acknowledged that they did not follow the aggression care plan directive to avoid confrontation and adjust the plan of care to reduce incidents of aggression when possible, and confirmed that the facility did not prevent the two residents from being outside together despite the prior conflict.
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