F0657

D

Failure to Revise Care Plan After Resident-to-Resident Physical Altercation

Wall, New Jersey Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately revise the care plan for a resident after an incident of resident-to-resident physical aggression. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, aphasia, apraxia, and speech disturbances, and had a BIMS score of 7/15, indicating severe cognitive impairment. On 1/10/26, a verbal argument occurred between Resident #3 and their roommate, Resident #1, related to the television remote control. RN #1 entered the room and observed Resident #3 waving the television remote, appearing frustrated, and pushing the bedside table toward Resident #1, bumping Resident #1 in the abdomen. Progress notes by UM #1 documented that Resident #3 had a verbal argument with the roommate and became frustrated, pushing the table at the roommate.

Following this incident, the facility updated Resident #3’s care plan with a focus on difficulty expressing themselves due to expressive aphasia and added interventions such as providing emotional support and allowing time to express feelings. However, the care plan did not include any interventions addressing how the facility would protect the roommate or other residents when Resident #3 became frustrated in the absence of staff, nor did it include measures to address Resident #3’s risk of physically acting out toward others. During an interview, the DON and the Licensed Nursing Home Administrator confirmed that the updated interventions would not prevent Resident #3 from another altercation with another resident when staff were not present. This failure to include adequate, person-centered interventions to address the underlying source of the problem and to protect other residents constituted the cited deficiency.