F0657

D

Failure to Revise Care Plan After Repeated Resident-to-Resident Incidents

Port Arthur, Texas Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after significant behavioral incidents, as required. The resident was a female with schizoaffective disorder, cerebral infarction with resulting aphasia and dysphagia, anxiety disorder, seizures, and severely impaired cognition (BIMS score of 00). Her quarterly MDS dated 06/22/2025 showed she was sometimes able to make herself understood, usually understood others, and required moderate to maximum assistance with most ADLs and mobility, using a manual wheelchair with supervision or touching assistance. Her care plan, last revised on 11/03/2025, documented a history of physical aggression toward staff and other residents and included general interventions such as PRN medications, anticipating needs, communication techniques, behavior monitoring, psychiatric consults as indicated, and notification of appropriate authorities.

Despite this history and the presence of two documented resident-to-resident incidents, the care plan was not updated to reflect these specific events or any new interventions. On 07/18/2025, progress notes and an incident report authored by an LVN documented that the resident, while in a wheelchair in the hallway, grabbed another resident by the hands and slapped the other resident on the left side of the face. The CNA who witnessed the event immediately separated the residents, and the LVN completed a head-to-toe assessment, pain assessment, and vital signs, with no injuries or pain noted. A provider investigation report dated 07/22/2025 confirmed that the resident hit another resident on the left side of the face/neck, that both residents had no injuries, and that behavioral monitoring was initiated for 72 hours. However, the comprehensive care plan showed no revisions or added interventions related to this incident.

A second incident occurred on 08/16/2025, documented in progress notes and an incident report by another LVN. A CNA reported that the resident hit her roommate twice in the chest after an interaction involving the roommate’s bed linens. The residents were separated, both were assessed with no injuries noted, and the resident denied pain by shaking her head. A provider investigation report dated 08/16/2025 confirmed that the resident hit another resident on the chest, that both residents had no injuries, and that behavioral monitoring was again initiated for 72 hours. Interviews with the LVNs indicated that staff viewed the resident’s hitting/patting as a way to gain attention due to her being nonverbal, and that they followed facility protocols for assessment, monitoring, separation, and notification of authorities. Nonetheless, review of the care plan showed no interventions added since 06/17/2024 and no updates to reflect these two resident-to-resident incidents.

Interviews with the MDS Coordinator, DON, and Administrator further clarified the inaction that led to the deficiency. The MDS Coordinator stated that incidents and allegations were discussed in morning meetings and that she recalled discussing the July and August incidents involving this resident, believing at the time that the care plan had been updated. She acknowledged that the care plan should have been revised to reflect the resident’s current needs and the interventions used, including monitoring, authority notification, and communication techniques, and admitted she had forgotten to update the care plan. The DON stated that all incidents were discussed in morning meetings, that the MDS Coordinator was responsible for revising care plans, and that new interventions should be added for recurrent resident-to-resident altercations; she did not know why the care plan had not been updated. The Administrator stated that the MDS Coordinator and DON were responsible for ensuring care plans were updated and recognized that failure to revise care plans could result in residents not receiving needed care. Both the DON and MDS Coordinator reported that the facility had no specific policy for care plan updating or revision and that they followed the RAI Manual, which states that significant changes requiring interdisciplinary review and/or care plan revision include major declines or improvements that are not self-limiting and affect more than one area of health status.

The combined record review and staff interviews demonstrated that, although the resident experienced at least two documented resident-to-resident physical contact incidents and was placed on behavioral monitoring each time, the interdisciplinary team did not revise the comprehensive care plan to incorporate these events or any specific, updated interventions. The care plan remained unchanged with no new interventions added since 06/17/2024, despite the resident’s ongoing behavioral issues and the subsequent incidents. This failure to update the care plan after each assessment and incident constituted the cited deficiency in care planning for this resident.