Failure to Update Care Plan for Ongoing Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s person-centered comprehensive care plan to reflect current aggressive behaviors. The resident, a 75-year-old female admitted with diagnoses including severe unspecified dementia without behavioral disturbance, type 2 diabetes mellitus, delusional disorder, depression, and hypertension, had an MDS assessment showing a BIMS score of 2, indicating severe cognitive impairment. The same MDS documented physical behavioral symptoms directed toward others, verbal behavioral symptoms, and other behavioral symptoms occurring multiple days during the look-back period. Despite these documented behaviors, the comprehensive care plan dated 10/31/2025 did not include an aggressive behavior problem area, related goals, or interventions. Nursing progress notes documented multiple episodes of escalating aggressive behavior over several weeks. On 9/17/2025, staff documented the resident throwing items off the counter, hitting staff, cussing at staff, throwing offered water on the floor, and being on 1:1 observation. On 9/24/2025, notes indicated physically aggressive behavior toward staff and that the resident pushed another resident down when touched, with reports of increased aggressive behaviors during the day. On 10/3/2025, documentation showed the resident was physically aggressive toward nursing staff when they attempted to redirect her. These entries demonstrated ongoing and increasing aggressive behaviors that were recorded in the nursing notes but not incorporated into the resident’s care plan. Interviews with facility leadership confirmed that the care plan was not updated to reflect the resident’s aggressive behaviors despite policy requirements. The DON stated she was familiar with the Care Planning policy, acknowledged that the MDS coordinator was responsible for completing care plans with input from the IDT, and agreed that the resident’s aggressive behaviors should have been documented in the care plan but did not know why this had not occurred. The ADON reported recent training on the Care Plans policy and stated that the resident’s care plan needed to be updated as soon as behaviors were reported by staff. The ADM also confirmed prior training on care planning, stated that the resident’s physical aggression should be documented in the care plan as soon as it was noticed or as soon as possible, and noted that while the behaviors were documented in nursing progress notes, they were not reflected in the care plan. Review of the facility’s Care Planning policy showed that care plans must incorporate identified problem areas, risk factors, measurable goals, and be revised as residents’ conditions change, which did not occur in this case.
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