Failure to Timely Implement Individualized Care Plan for Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to timely develop and implement a comprehensive, individualized, person-centered care plan to address a resident’s known aggressive behaviors. The resident was admitted with diagnoses including paranoid schizophrenia and diabetes mellitus, and had documented episodes of aggression. On one occasion, an SBAR Communication Form recorded that the resident was in the hallway attempting to hit others. A subsequent Skilled Nursing Facility to Hospital Transfer Form documented that the resident was transferred to a general acute care hospital for aggressive behavior, shouting, screaming, and attempting to hit others. Following a 5150 psychiatric hold for being physically aggressive to staff, the resident was readmitted, and a care plan addressing aggressive behavior was initiated on 9/26/2025. However, this care plan was not individualized or resident-specific. It lacked documented monitoring parameters, did not identify behavioral triggers, and did not provide staff guidance on how to approach, redirect, and manage the resident’s aggressive behaviors. Although the care plan problem was opened on 9/26/2025, the specific interventions were not added or implemented until 11/5/2025, resulting in a significant delay in putting any concrete strategies into practice. The resident’s MDS dated 11/3/2025 indicated severely impaired cognition and a need for partial/moderate assistance with ADLs and mobility, underscoring the need for clear, structured behavioral interventions. During interviews, an RN and the DON both acknowledged that the care plan did not reflect a comprehensive, individualized, person-centered approach and was missing resident-specific guidance related to monitoring, triggers, and staff direction for managing aggressive behaviors. The facility’s own policy on comprehensive, person-centered care plans requires measurable objectives, timeframes, and services derived from thorough assessment and ongoing review, including after hospital readmission, which was not followed in this case.
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