Failure to Revise Care Plans After Repeated Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans for multiple residents after substantiated resident-to-resident abuse incidents involving the same aggressor. Facility records, including final synopses of events and progress notes, documented that one resident repeatedly struck or otherwise physically contacted other residents on the memory care unit, typically when others entered her personal space or touched staff she was interacting with. Despite these documented abuse events and follow-up psychosocial support visits, the comprehensive care plans for the abused residents did not contain any information related to the incidents or any updated approaches following the altercations. For one resident, an event synopsis dated in February described that she was struck on the right side of her face by another resident who became combative on the memory care unit. Staff who frequently cared for both residents reported that both wandered throughout the unit and that the aggressor could become agitated and combative when residents were in her personal space. A progress note documented a support visit related to the altercation, during which the abused resident was unable to recall the event but stated she felt safe and happy. However, review of her comprehensive care plan, dated the prior month, showed no information related to this abuse incident. Another resident experienced multiple separate incidents with the same aggressor in April. Facility synopses and nursing notes documented that the aggressor allegedly struck this resident in the face and nose after the resident got into the aggressor’s personal space and food, and on another occasion punched her in the upper lip after the resident grabbed a CNA’s arm. Notes described small red marks and later separation of the residents, but the comprehensive care plan, dated in February, contained no entries related to these abuse incidents. Similarly, a third resident was documented as being hit on the right side of her face by the same aggressor after the aggressor became combative in the bathroom area; progress notes described assessment and a follow-up visit related to a negative encounter with another resident, but her care plan, dated in March, lacked any abuse-related information. A fourth resident had at least two documented abuse incidents with the same aggressor. In June, progress notes recorded that she was sitting in her wheelchair when the aggressor approached and hit her in the face with a comb; assessment at that time showed no injuries, and a support visit later that day documented that she had no recall of the encounter and stated she felt safe. In November, another incident was documented in which the aggressor hit her in the face with a padded box after she gently touched the aggressor’s arm; subsequent notes recorded bruising to the upper lip and a follow-up visit where the resident did not recall the negative encounter or provide information about her comfort level among others. Review of her comprehensive care plan, dated the previous December, revealed no information related to any of these abuse incidents. Interviews with facility staff confirmed that the care plans for these abused residents were not updated after the incidents. The director of social services stated she is responsible for following up on psychosocial needs after resident-to-resident altercations and that the abused resident’s care plan should be updated after any such event. A registered nurse explained that the care plan is used to ensure all care team members provide appropriate care and that it should be updated for any victim of abuse, noting that unit managers ordinarily update care plans. A unit manager LPN stated that care plans should be updated after an incident of abuse because such an event could trigger a trauma response, and that floor nurses do not typically update care plans. The facility’s own policy on comprehensive person-centered care planning stated that the interdisciplinary team is responsible for reviewing and updating care plans when there has been a significant change in condition or when goals, needs, and preferences change, yet the care plans for the four residents remained unrevised regarding the documented abuse events.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.