F0656

E

Failure to Care Plan Resident-to-Resident Physical Altercations and Behavioral Risks

San Antonio, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents who were involved in resident-to-resident physical altercations. For one resident with schizophrenia, anxiety disorder, and mild cognitive impairment, progress notes documented that staff heard yelling and found him standing over his roommate with his fist raised, and the resident stated he had punched the roommate because of how the roommate spoke to him. Despite this documented incident of physical aggression, the resident’s care plan, with a target date of 01/07/2026, did not include any problem, goal, or interventions addressing his physical aggression toward another resident. Subsequent observations showed the resident interacting with others without aggressive behavior, and he denied the incident during interview, but the absence of a behavior-related care plan remained.

Another resident with schizoaffective disorder, anxiety disorder, and paraplegia had a Significant Change MDS showing intact cognition and behavioral symptoms not directed toward others. A progress note documented that staff heard yelling, entered the room, and found this resident lying in bed with his roommate standing over him with a balled fist above his head; the resident reported being hit in the head, after which he was removed and assessed. His care plan, with a target date of 02/02/2026, did not include any care plan entry reflecting that he had experienced physical aggression from another resident. During interviews, the resident reported only one such incident, stated staff had moved him from the room, and denied having exhibited behaviors himself. The social worker and the MDS LVN both reviewed the care plans and confirmed they could not locate behavior-related care plan entries for either resident, despite stating that such incidents were typically care planned to provide interventions and alert staff to behaviors and safety concerns.

Two additional residents with significant cognitive impairment and behavioral histories were also involved in resident-to-resident altercations without corresponding updates to their care plans. One resident with Alzheimer’s disease, diabetes, and depression had an incident report documenting that she hit another resident in a secure unit; staff separated them and assessed both residents with no injuries noted, and an IDT meeting the next day identified new interventions such as 15-minute checks and referral to psychiatric services. However, her comprehensive care plan did not reflect the altercation or the new interventions. Another resident with dementia, psychotic disorder, depression, and hallucinations had an incident report indicating he pulled another resident out of bed because the other resident was sleeping in his bed; staff separated and assessed them with no injuries noted, and an IDT meeting identified new interventions including 15-minute checks and psychiatric referral. His comprehensive care plan likewise did not include the altercation or the new interventions. The social worker acknowledged forgetting to create behavior care plans for these residents after the IDT meetings, despite facility policy requiring comprehensive, person-centered care plans that incorporate identified problem areas, risk factors, measurable objectives, and timeframes.