Failure to Revise Care Plan for Resident’s Inappropriate Behaviors During Care
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive, person-centered care plan to address documented inappropriate behaviors toward staff during ADL care. Facility policy on Person-Centered Care Planning, revised 4/24/25, requires development, implementation, review, and revision of comprehensive care plans with measurable objectives and timeframes after each comprehensive and quarterly assessment to meet residents’ medical, nursing, mental, and psychosocial needs. Medical record review for Resident 5, who was admitted with contractures of both hands and had an H&P dated 5/16/25 indicating no capacity to understand and make decisions, showed that the resident’s plan of care did not contain a problem or interventions addressing inappropriate behavior toward staff during care. During an interview on 2/25/26, CNA 12 reported that Resident 5 occasionally swung his arms toward her once or twice a week when she provided ADL care, and that he would cooperate when she returned later and encouraged him. In a telephone interview the same day, LVN 5 stated that Resident 5 had contracted fingers but could move his arms, had a history of removing Kerlix rolls, scratching and picking his skin, and swinging his arms at staff during care. LVN 5 further stated that the behavior of swinging his arms at staff during care was not documented and should have been included in the care plan. On 2/26/26, the DON confirmed during interview and concurrent record review that Resident 5’s plan of care had not been updated to reflect this inappropriate behavior toward staff during care, and on 2/27/26 the Administrator and DON were informed of and acknowledged these findings.
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