F0656

D

Failure to Update Behavior Care Plan After Resident-to-Resident Altercation

Corrigan, Texas Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes addressing a resident’s behavior toward other residents after a documented incident of aggression. One male resident with diagnoses including hemiplegia and hemiparesis following stroke, intermittent explosive disorder, personality change due to a physiological condition, and anxiety disorder had a significant change MDS indicating he was cognitively intact (BIMS-15) and usually able to make himself understood and understand others, with no aggressive behaviors noted on that assessment. His existing care plan, dated several months prior, identified him as aggressive and argumentative with staff, with interventions such as administering medications as ordered, intervening to protect the rights and safety of others, and referral to counseling services. However, this care plan was not reviewed or updated to address his behavior toward other residents after a specific resident-to-resident incident.

On a date in November, an incident report completed by an LVN documented that this resident, while in the dining room, hit another male resident with a fly swatter. When questioned, the resident stated that the other resident had called him his “kid brother” and that he wanted to aggravate him, so he hit him with the fly swatter. The facility’s investigation confirmed that the resident hit the other resident with a fly swatter, that both residents were separated and assessed, and that there were no injuries. The second resident, who had diagnoses including Parkinson’s disease, anxiety, and schizoaffective disorder–bipolar type, had a significant change MDS showing moderate cognitive impairment (BIMS-9), an acute change in mental status with fluctuating inattention and disorganized thinking, and no aggressive behaviors noted. His care plan identified a behavior problem related to bipolar disorder with weekly counseling services, but there is no indication in the report that his care plan was revised in response to the altercation.

Interviews further clarified the circumstances and the lack of care plan revision. The second resident reported that the first resident hit him with a fly swatter to bother him after he referred to the first resident as his little brother, that he was not hurt, and that he was not afraid and remained friends with him. The first resident stated he hit the other resident to irritate him and not to cause harm. A third resident reported witnessing the incident, stating that the first resident was trying to irritate the second resident, who became upset and moved to another table, and that he had not previously seen the first resident hit this or any other resident. The Administrator and DON acknowledged there was no prior history of aggression by the first resident toward other residents and stated that the care plan was supposed to be reviewed and updated after the incident and upon readmission from a behavioral hospital, but this was not completed or saved in the electronic record. The facility’s own policy on resident-to-resident altercations required making necessary changes in care plan approaches for involved residents and documenting interventions and their effectiveness, which was not carried out in this case.